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Surgical treatment of supracondylar humerus fractures in children

The Treatment of Pediatric Supracondylar Humerus Fractures AUC

PURPOSE OF THE STUDY: Surgical techniques for the treatment of supracondylar fractures in children are repeatedly the subject of discussion. The aim of the present study was to compare experience with the technique of crossed Kirschner wires at our own hospital with current literature. PATIENTS AND METHODS: In the period from 2000-2006 a total of 86 children aged 1.7 to 12.7 years were treated by means of crossed K-wire osteosynthesis. Follow up was conducted at an average of 32 months. Outcomes were evaluated based on von Laer's criteria. RESULTS: Reported complications were migration of the K-wires in 7% of cases and secondary dislocation and re-operation in 4% of cases. Lesion of the radial nerve was diagnosed postoperatively in two cases. Hospital stay was 1.5 days on average. Postoperative immobilization in an upper arm splint and implant removal after 6 weeks on average. 57% of the children received physiotherapy during the course of treatment. Slight varization was found in 11% of children and an unsatisfactory range of motion in 13%. Satisfactory outcomes were recorded for 83% of patients. CONCLUSION: K-wire osteosynthesis is associated with a low complication rate and continues to be a safe standard procedure for the stabilization of supracondylar humerus fractures. Key words: supracondylar humerus fracture, Kirschner wires, paediatric fractures

Near-infrared spectroscopy: a potential method for continuous, transcutaneous monitoring for compartmental syndrome in critically injured patients

DOD - Acute Comp Syndrome CPG

BACKGROUND: Near-infrared spectroscopy (NIRS) noninvasively measures tissue O2 saturation (StO2), and has been proposed as a means of monitoring for compartmental syndrome (CS). However, its specificity in hypoxemic, hypotensive patients with severely reduced systemic oxygen delivery has not been tested. We hypothesized that NIRS can differentiate muscle ischemia caused by shock from ischemia caused by CS. METHODS: Nine swine were anesthetized and an NIRS probe placed over the anterolateral compartment of the hind leg. Compartment pressure was also measured. A nerve stimulator was placed over the peroneal nerve, and CS was defined as loss of dorsiflexion twitch. At 30-minute sequential intervals, mean arterial blood pressure was reduced to 60% of baseline (phlebotomy), fraction of inspired oxygen was reduced to 0.15, and compartment pressure was increased in one limb by interstitial albumin infusion until CS occurred. RESULTS: Hypotension combined with hypoxemia reduced StO2 from 82+/-4% to 66+/-10%. CS further reduced StO2 to 16+/-12% (p<0.0001). During hypotension + hypoxemia + CS, control limb StO2 was 70+/-15% (p = 0.0002 vs. experimental limb). CONCLUSION: NIRS detects muscle ischemia caused by CS despite severe hypotension and hypoxemia, making it potentially useful in critically injured, unstable patients.

Polyethylene wear particle generation in vivo in an alumina medial pivot total knee prosthesis

Surgical Management of Osteoarthritis of the Knee CPG

Polyethylene wear particle generation is one of the most important factors affecting mid- to long-term results of total knee arthroplasties. It has been reported that the medial pivot total knee prosthesis (MP) design and alumina ceramic femoral component reduce polyethylene wear. The aim of this study is to evaluate in vivo polyethylene wear particle generation in the newly introduced alumina MP, in comparison with a metal MP. Synovial fluid was obtained from 11 knees with alumina MP and 15 knees with metal MP at nine months after the operation. Polyethylene particles were isolated, and examined using scanning electron microscope and image analyzer. Total number of particles in each knee was 7.10+/-2.86x10(6) in alumina (mean+/-standard error), and 5.70+/-2.82x10(7) in metal MP (p=0.048). Particle size (equivalent circle diameter) was 0.78+/-0.04 microm in alumina, and 0.66+/-0.06 microm in metal MP (p=0.120). Particle shape (aspect ratio) was 1.52+/-0.05 in alumina, and 1.88+/-0.11 in metal MP (p=0.014). Apart from the femoral component, the material and manufacturing method of polyethylene insert differed between the two groups, although the sterilization method was the same. Alumina MP generated fewer and rounder polyethylene wear particles than metal MP in early clinical stage, and could potentially reduce prevalence of osteolysis and aseptic loosening

Patient education for adults with rheumatoid arthritis

SR for PM on OA of All Extremities

Background: Because of the unpredictability people with arthritis face on a daily basis, patient education programmes have become an effective complement to traditional medical treatment giving people with arthritis the strategies and the tools necessary to make daily decisions to cope with the disease.Objectives: To assess the effectiveness of patient education interventions on health status in patients with rheumatoid arthritis.Search methods: We searched MEDLINE, EMBASE and PsycINFO and the Cochrane Controlled Trials Register. A selection of review articles (see references) were examined to identify further relevant publications. There was no language restriction.Selection criteria: Randomised controlled trials (RCT's) evaluating patient education interventions that included an instructional component and a non-intervention control group; pre- and post-test results available separately for RA, either in the publication or from the studies' authors; and study results presented in full, end-of-study report.Data collection and analysis: Two reviewers examined and screened search results. Dichotomous items were summarized as relative risk. Standardized mean difference and weighted mean difference were calculated for continuous data. Heterogeneity was assessed using chi square.Main results: Thirty-one studies with relevant data were included. We found significant effects of patient education at first follow-up for scores on disability, joint counts, patient global assessment, psychological status, and depression. A trend favouring patient education was found for scores on pain. Physician global assessment was not assessed in any of the included studies. The dimensions of anxiety and disease activity showed no significant effects. At final follow up no significant effects of patient education were found, although there was a trend favouring patient education for scores on disability.Authors' conclusions: Patient education as provided in the studies reviewed here had small short-term effects on disability, joint counts, patient global assessment, psychological status and depression. There was no evidence of long-term benefits in adults with rheumatoid arthritis

Discoid lateral meniscus - Results of arthroscopic management

AMP (Acute Meniscal Pathology)

Nine patients with symptomatic lateral discoid meniscus were treated arthroscopically between April, 1992 and September, 1994. Partial menisectomy and shaving the inner edges to mimic the normally-shaped meniscus was the preferred operative procedure. Lysholm knee score and scale of lkeuchi were used to assess treatment results, with a mean follow-up period being 28.9 months. Satisfactory result was found in eight patients (88.9%), but one patient with complex tear of the meniscus had poor result. Post-operative improvement was statistically significant.

A double-blind, placebo-controlled, randomized trial of oral sodium clodronate for metastatic prostate cancer (MRC PR05 Trial)

MSTS 2018 - Femur Mets and MM

BACKGROUND: The most frequent site of metastases from prostate cancer is bone. Bisphosphonates reduce excessive bone turnover while preserving bone structure and mineralization in patients with other tumor types. We conducted a double-blind, placebo-controlled, randomized trial to determine whether the first-generation bisphosphonate sodium clodronate could improve bone progression-free survival (BPFS) times among men with bone metastases from prostate cancer. METHODS: Between June 1994 and July 1998, 311 men who were starting or responding to first-line hormone therapy for bone metastases were randomly assigned to receive oral sodium clodronate (2080 mg/day) or placebo for a maximum of 3 years. The primary endpoint of the trial was symptomatic BPFS. Secondary endpoints included overall survival, treatment toxicity, and change in World Health Organization (WHO) performance status. Time-to-event data were analyzed using the log-rank chi-square test and Kaplan-Meier curves. All statistical tests were two-sided. RESULTS: Baseline characteristics were balanced across the two groups. After a median follow-up of 59 months, the sodium clodronate group showed statistically nonsignificant better symptomatic BPFS (hazard ratio [HR] = 0.79, 95% confidence interval [CI] = 0.61 to 1.02; P =.066) and overall survival (HR = 0.80, 95% CI = 0.62 to 1.03; P =.082) than the control group. Patients in the clodronate group were less likely to have a worsened WHO performance status (HR = 0.71, 95% CI = 0.56 to 0.92; P =.008). However, the clodronate group reported more gastrointestinal problems and increased lactate dehydrogenase levels and required more frequent modification of the trial drug dose (HR for any adverse event = 1.71, 95% CI = 1.21 to 2.41; P =.002). Results of subgroup analyses suggested that clodronate might be more effective the sooner after diagnosis of metastatic bone disease it is started. CONCLUSION: These results suggest that further studies of the effect of newer generation bisphosphonates on BPFS in men with metastatic prostate cancer are warranted.

Posterior fully threaded positioning screw prevents femoral neck collapse in Garden I or II femoral neck fractures

Hip Fx in the Elderly 2019

Introduction: Osteosynthesis is recommended for Garden I and II femoral neck fracture treatment using parallel partially threaded cannulated screws. Postoperatively, excessive femoral neck shortening (FNS) and posterior tilt of the femoral neck (PTFN) are frequently encountered and are correlated with impaired quality of life and clinical outcomes. We hypothesized that stabilization by parallel partially threaded cannulated screws replacing a posterior partially threaded screw with a fully threaded positioning screw would improve fracture healing without further FNS and PTFN in femoral neck fractures. Methods: We retrospectively reviewed Garden I and II femoral neck fractures treated by in situ fixation using parallel cannulated screws at our institution between January 2010 and November 2018. Patients with the applicable fractures were divided according to the utilization of posterior fully threaded screws: patients with partially threaded screws were included in Group C and those with posterior fully threaded screws were included in Group P. Intergroup comparisons were performed based on radiographic measurements that assessed the shortening in two vectors (the horizontal and vertical axes), FNS, and subsequent PTFN. Results: No significant intergroup difference was found in demographics and fracture characteristics, except in the follow-up duration. The mean FNS and shortening in both vectors were significantly smaller in Group P than in Group C (FNS, 5.02 ± 1.31 vs. 8.84 ± 3.48 mm, p < 0.001; horizontal axis, 4.07 ± 1.06 vs. 6.18 ± 2.77 mm, p < 0.001; and vertical axis, 2.55 ± 1.68 vs. 5.74 ± 3.41 mm, p < 0.001). The mean subsequent PTFN was significantly smaller in Group P (2.21 ± 2.99 vs. 7.56 ± 6.20 mm, p < 0.001). A significantly smaller number of patients in Group P had moderate (5–10 mm) or severe (>10 mm) FNS and moderate (5–10°) or severe (>10°) subsequent PTFN. Conclusion: Parallel cannulated screws replacing a posterior partially threaded screw with a fully threaded positioning screw as a length- and angle-stable construct for Garden I or II femoral neck fracture fixation can prevent femoral neck collapse in both the coronal and axial planes.

Computed tomography characteristics of the acetabulum in developmental dysplasia of the hip

Developmental Dysplasia of the Hip 2020 Review

Background: Low-dose computed tomography (CT) is the preferred method for post-reduction evaluation of hips of infants in spica casts, but the assessment of acetabular morphological features in developmental dysplasia of the hip (DDH) using CT has not be done before. Objectives: To determine CT imaging characteristics of the acetabulum in DDH and to be able to determine DDH in pelvic CT examinations performed for different purposes. Patients and Methods: CT images of 102 consecutive patients with DDH (90 females, 12 males) and 51 age-matched controls (26 females, 25 males) were included in this study. Acetabular shape abnormalities, surface irregularity, subcortical sclerosis, shallowing, and measurement of acetabular cortical bone thickness were evaluated in coronal reformatted images. Differences in the cortical thickness of dysplastic and normal hips were assessed. Results: Forty-four patients (43.1%) had unilateral and 58 had bilateral DDH (56.9%). Acetabular margin irregularity was present in all patients with unilateral DDH and 55 of the 58 patients with bilateral DDH (94%). Thickening on the inferior part of the ilium compared to the normal side was seen in 41 of the 44 unilateral DDH patients (93%). In the 44 patients with unilateral DDH, the mean cortical thickness measured from the central part of the acetabulum was 0.86 ± 0.03 mm and 0.65 ± 0.03 mm on the normal and dysplastic sides, respectively (P = 0.0001). This difference was more distinct at the acetabular rim, measuring 1.11 ± 0.06 mm and 0.70 ± 0.04 mm on normal and dysplastic sides, respectively (P = 0.0001). Conclusion: Acetabular marginal irregularity and flattening is a reliable finding in the diagnosis of DDH when combined with thickening on the inferior part of ilium and will help in the diagnosis of DDH in patients older than 6 months old with a pelvic CT scan due to diseases other than DDH.

Double contrast knee arthrography in the evaluation of osteochondritis dissecans

Diagnosis and Treatment of Osteochondritis Dissecans AUC

Double contrast knee arthrography is an invaluable adjunct in the evaluation of patients with osteochondritis dissecans. The cartilage overlying the osteochondritic defect can be evaluated and unsuspected meniscal pathology accurately diagnosed. In our series, there were three unsuspected medial meniscal tears, diagnosed by arthrography and confirmed at surgery. The location of the osteochondritic defect was atypical in all four of our female patients

Inclusion of Olecranon Osteotomy with the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications

Pediatric Supracondylar Humerus Fracture 2020 Review

OBJECTIVES: To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13). DESIGN: Retrospective comparative cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: 304 patients underwent open reduction internal fixation (ORIF) of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (15 years old, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy). INTERVENTION: ORIF of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy. MAIN OUTCOME MEASUREMENT: Ulnar neuropathy (UN), fracture site bony nonunion, surgical site infection (SSI). RESULTS: 31 (33.3%) who underwent the paratricipital approach without olecranon osteotomy and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P= 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P= 0.263) when comparing the approaches. Subjects with CCI =2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001). CONCLUSIONS: Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Global guidance for surgical care during the COVID-19 pandemic

Coronavirus Disease 2019 (COVID-19)

BACKGROUND: Surgeons urgently need guidance on how to deliver surgical services safely and effectively during the COVID-19 pandemic. The aim was to identify the key domains that should be considered when developing pandemic preparedness plans for surgical services. METHODS: A scoping search was conducted to identify published articles relating to management of surgical patients during pandemics. Key informant interviews were conducted with surgeons and anaesthetists with direct experience of working during infectious disease outbreaks, in order to identify key challenges and solutions to delivering effective surgical services during the COVID-19 pandemic. RESULTS: Thirteen articles were identified from the scoping search, and surgeons and anaesthetists representing 11 territories were interviewed. To mount an effective response to COVID-19, a pandemic response plan for surgical services should be developed in advance. Key domains that should be included are: provision of staff training (such as patient transfers, donning and doffing personal protection equipment, recognizing and managing COVID-19 infection); support for the overall hospital response to COVID-19 (reduction in non-urgent activities such as clinics, endoscopy, non-urgent elective surgery); establishment of a team-based approach for running emergency services; and recognition and management of COVID-19 infection in patients treated as an emergency and those who have had surgery. A backlog of procedures after the end of the COVID-19 pandemic is inevitable, and hospitals should plan how to address this effectively to ensure that patients having elective treatment have the best possible outcomes. CONCLUSION: Hospitals should prepare detailed context-specific pandemic preparedness plans addressing the identified domains. Specific guidance should be updated continuously to reflect emerging evidence during the COVID-19 pandemic.

Coronary heart disease risk factors after total joint arthroplasty of the hip and knee

Surgical Management of Osteoarthritis of the Knee CPG

To describe the changes that occur in coronary heart disease (CHD) risk factors following total joint arthroplasty of the hip and/or knee, we evaluated 31 patients with end-stage arthritis immediately prior to operation and for a period of up to 2 years post-operatively. Nineteen arthritic individuals undergoing medical treatment for their disease served as a control group. A panel of potentially modifiable metabolic risk factors were measured, including body mass index, waist:hip ratio, blood pressure, blood glucose, and serum lipids and apoproteins. Predicted 10-year CHD event rate, an aggregate measure of overall risk, was calculated for each subject. Compared to surgical patients, controls were observed to have increases in apoprotein A-1 levels (p = 0.01) and a fall in the ratio of apoprotein B-100 to apoprotein A-1 (p = 0.004), both findings indicating a reduction in CHD risk. No other statistically significant differences over time were observed between patients and controls in morphometric measures, blood pressure indices, fasting glucose, lipid levels or predicted CHD event rate. These results were consistent, regardless of the joint replaced, baseline fitness level, or the presence or absence of improvements in fitness during the follow-up period. We conclude that patients with end-stage lower extremity arthritis receiving contemporary, conservative post-operative care do not experience significant improvement in their risk for CHD after arthroplasty. More intense strategies to improve CHD risk, possibly with greater emphasis on aerobic exercise and weight reduction, may be appropriate following joint replacement

Bridging plate osteosynthesis of humeral shaft fractures

Distal Radius Fractures

This study was approved by the Ethics Committee of the Faculty of Medical Sciences and developed during November 2000 and July 2001 in the Orthopedic and Traumatology Department of UNICAMP. There were 15 patients, 11 males, age between 14 and 66 years. All fractures were unilateral. Of the 15 patients eight were polytraumatised, two of them had open fractures. The others had an isolated fracture of the humerus, of which one was open. None of the patients had previous lesions of the radial nerve, but in two patients there was a lesion of the brachial plexus. All of the patients underwent a bridging plate osteosynthesis of the humeral shaft fractures using only two small incisions proximal and distal to the fracture site. We used broad or narrow D.C.P. plates for large fragments mostly with 12 holes, fixed with two or three screws at each end. All cases united with an average time of 8-12 weeks, with the exception of one case with a grade III open fracture and a brachial plexus lesion on the same side. We had no major complications. All patients recovered good function of the limb without significant residual deformity.

The association between delirium and the apolipoprotein E epsilon 4 allele: new study results and a meta-analysis

Management of Hip Fractures in the Elderly

OBJECTIVES: To determine a possible association between Apolipoprotein E (APOE)sigma4-allele and delirium in a large cohort and combining these current data with former studies in a meta-analysis. Design: Combination of a new prospective cohort study and meta-analysis. SETTING: Medical department and orthopedic/traumatology department of University hospital from 2003 to 2007. Participants: A total of 656 patients aged 65 years and older acutely admitted with a medical diagnosis or after hip fracture. MEASUREMENTS: Confusion Assessment Method for delirium, Informant Questionnaire on Cognitive Decline-short form for predelirium global cognitive impairment, and Katz Index of Activities of Daily Living for functionality. APOE was genotyped by mass spectrometer. A meta-analysis was performed combining the current data with published studies analyzing the association between the APOE sigma4-allele and the delirium. RESULTS: : The 49% of the 76 surgical patients and 35% of the 580 medical patients experienced delirium. Delirious patients were significantly older (82 versus 77 years) and had more frequently functional (66% versus 26%) and cognitive impairment (86% versus 29%) than nondelirious patients. The odds ratio (OR) for delirium adjusted for age, cognitive, and functional impairment of sigma4 carriers compared with non-sigma4 carriers was 1.7 (95% confidence interval [CI]: 1.1-2.6). Four studies were added to the meta-analysis, which included 1,099 patients in total. The OR for delirium in the meta-analysis was 1.6 (95% CI: 0.9-2.7) of sigma4 carriers compared with non-sigma4 carriers. CONCLUSIONS: This study and meta-analysis suggest an association between delirium and the APOE sigma4 allele

Diagnosis and treatment of common knee injuries in athletes

AMP (Acute Meniscal Pathology)

Knee injuries are an all too common occurrence in athletes. Prompt diagnosis, aggressive treatment and rehabilitation is necessary to minimize time away from athletic activity and to maximize function at a competitive level. This article reviews the latest trends in diagnosing and treating common knee injuries in athletes, including ligamentous and meniscal injuries. [References: 20]

Systematic review of the management of chronic compartment syndrome in the lower leg

DOD - Acute Comp Syndrome CPG

Objectives: To review the literature and identify current management strategies used in the treatment of chronic compartment syndrome and discuss their effectiveness. Design: Systematic review of papers published between 1980 to 2002 which focused primarily on the conservative or surgical management of chronic compartment syndrome of the lower leg. The articles were mainly expert opinions or retrospective surgical cases. Consequently a modified assessment criteria had to be devised to critique the quality of the papers. Data Source: Medline, Pedro, Cochrane, Science Direct, Sports Rehab and hand searching of relevant articles cited in the review papers. Results: Of the 83 articles generated, 14 articles were found to concentrate on the management of compartment syndrome of the lower leg. The other articles dealt mainly with the anatomy, pathophysiology or diagnostic techniques and were therefore excluded from the review. The studies varied in the thoroughness of the diagnostic criteria, the pressure measurement techniques and the surgical method. Some papers described the conservative management used prior to surgery, however no statistical comparisons were made between outcomes of conservative therapy versus surgical intervention. The outcome measures used across the studies were primarily subjective in nature and follow-up times were not standardised. Conclusion: The quality of research in this area has large scope for improvement. Conservative management received little attention in the literature although most studies alluded to the fact that it had been unsuccessful in their patients. There is a strong need to explore this in greater depth. Although randomisation into surgical and conservative groups poses ethical dilemmas, researchers can overcome this by implementing a standardised conservative program in all patients prior to surgery. The quality of evidence to support surgical intervention needs to be more vigorous. At present, there is only anecdotal evidence to support surgical management over conservative, as treatment of choice in chronic compartment syndrome of the lower leg.

Double-blind clinical trial of S-adenosylmethionine versus ibuprofen in the treatment of osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Thirty�six subjects with osteoarthritis of the knee, the hip, and/or the spine were enrolled in a randomized double�blind study. Patients received a daily oral dose of 1,200 mg of S�adenosylmethionine (SAMe) or 1,200 mg of ibuprofen for four weeks. Morning stiffness, pain at rest, pain on motion, crepitus, swelling, and limitation of motion of the affected joints were assessed before and after treatment. The total score obtained by the evaluation of all the individual clinical parameters improved to the same extent in patients treated with SAMe or ibuprofen. Both treatments were well tolerated and no patient from either group withdrew from the study.

Subchondral Calcium Phosphate is Ineffective for Bone Marrow Edema Lesions in Adults With Advanced Osteoarthritis

PJI DX Updated Search

BACKGROUND: Injury to subchondral bone is associated with knee pain and osteoarthritis (OA). A percutaneous calcium phosphate injection is a novel approach in which subchondral bone marrow edema lesions are percutaneously injected with calcium phosphate. In theory, calcium phosphate provides structural support while it is gradually replaced by bone. However, little clinical evidence supports the efficacy of percutaneous calcium phosphate injections. QUESTIONS/PURPOSES: We asked: (1) Does percutaneous calcium phosphate injection improve validated patient-reported outcome measures? (2) What proportion of patients experience failure of treatment (defined as a low score on the Tegner Lysholm Knee Scoring Scale)? (3) Is there a relationship between outcome and age, sex, BMI, and preoperative grade of OA? METHODS: Between September 2012 and January 2014, we treated 33 patients with percutaneous calcium phosphate injections. Twenty-five satisfied our study inclusion criteria; of those, three patients were lost to followup and 22 (88%; 13 men, nine women) with a median age of 53.5 years (range, 38-70 years) were available for retrospective chart review and telephone evaluation at a minimum of 6 months (median, 12 months; range, 6-24 months). Our general indications for this procedure were the presence of subchondral bone marrow edema lesions observed on MR images involving weightbearing regions of the knee associated with localized pain on weightbearing and palpation and failure to respond to conservative therapy (> 3 months). Patients with pain secondary to extensive nondegenerative meniscal tears with a flipped displaced component at the level of bone marrow edema lesions, or with mechanical axis deviation greater than 8 degrees were excluded. All patients had Grades III or IV chondral lesions (modified Outerbridge grading system for chondromalacia) overlying MRI-identified subchondral bone marrow edema lesions. Percutaneous calcium phosphate injection was performed on the medial tibial condyle (15 patients), the medial femoral condyle (five patients), and the lateral femoral condyle (two patients). Concomitant partial meniscectomy was performed in 18 patients. Preoperative and postoperative scores from the Knee Injury and Arthritis Outcome Score (KOOS) and the Tegner Lysholm Knee Scoring Scale were analyzed. RESULTS: For patients available for followup, the outcome scores improved after treatment. The KOOS improved from a mean of 39.5 +/- 21.8 to 71.3 +/- 23 (95% CI, 18.6-45.2; p < 0.001) and the Tegner and Lysholm score from 48 +/- 15.1 to 77.5 +/- 20.6 (95% CI, 18.8-40.2; p < 0.001). However, seven of the 22 patients had poor clinical outcomes as assessed by the Tegner Lysholm Knee Scoring Scale, whereas three had fair results, five had good results, and seven had excellent results. The postoperative Tegner Lysholm score was inversely related to the preoperative Kellgren-Lawrence OA grade (R(2) = 0.292; F (1.20) = 9.645; p = 0.006). We found no relationship between outcome scores and age, sex, or BMI. CONCLUSIONS: In a study that would have been expected to present a best-case analysis (short-term followup, loss to followup of patients with potentially unsatisfactory results, and use of invasive cotreatments including arthroscopic debridements), we found that percutaneous calcium phosphate injection in patients with symptomatic bone marrow edema lesions of the knee and advanced OA yielded poor results in a concerning proportion of our patients. Based on these results, we advise against the use of percutaneous calcium phosphate injections for patients with advanced osteoarthritic changes. LEVEL OF EVIDENCE: Level IV, therapeutic study

Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study

DoD PRF (Psychosocial RF)

OBJECTIVE: Motor vehicle accidents (MVA) and work-related injuries are two of the more common causes of chronic pain. Nevertheless, there is little evidence on predicting factors regarding the development of chronic pain following physical injury. METHODS: The present study investigated temporal associations between accident-related factors, psychological factors [symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, coping], and the development of chronic pain in a sample of individuals who had sustained severe accidental injuries (N=90). Assessments were performed within 1 month of the accident, and at 6, 12, and 36 months post trauma. RESULTS: A total of 40 individuals (44%) reported accident-related pain 3 years after the accident. Individuals with chronic pain showed significantly more symptoms of PTSD, depression, and anxiety, more disability, and more days off work. Analysis of temporal associations between psychological variables and the development of chronic pain indicated that the separation of the pain from the nonpain group mostly occurred between 6 (T2) and 12 months (T3). Differences were much less pronounced at T1. CONCLUSION: The prevalence of chronic pain in severely injured patients 3 years after the accident is considerably high. The development of chronic pain is more related to psychological factors, particularly PTSD symptoms, in the aftermath of the accident, as compared to sociodemographic and accident-related variables at the time of the accident. These findings may be helpful to elucidate the problems in predicting chronic pain conditions in injured subjects and to recognize the onset of a chronic pain condition more reliably.

The three-dimensional analysis of kinematic gait parameters of subjects with gonarthrosis before and after total knee replacement

Surgical Management of Osteoarthritis of the Knee CPG

Background and Aims: The aim of the studies was an attempt to evaluate the variability of parameters of the lower limb joints of subjects before and after total knee replacement and its influence on ankle and hip joints. Angular values changes were studied in three planes of movement. Spatiotemporal parameters were also taken into consideration. Studies on the locomotion were carried out on 27 gonarthrosis subjects aged from 60 to 74. The control group consisted of 30 healthy persons aged 50-70, the so-called biomechanical norm. Methods: The gait was examined with the use of a computer system of three-dimensional movement analysis Vicon 250. Results: The limitations of extension in hip and knee joints have been observed. The varus arrangement and external rotation of knee joints has been visible. There have been no plantar flexion ankle joints at the beginning of swing phase. After total knee replacement the arrangement of hip and knee joints has improved insignificantly. The varus alignment has decreased but the external rotation has increased. There have been no changes in ankle joints function. The analysis of spatiotemporal parameters has shown diminished cadence and walking speed and shortened stride length. However the double support phase and stride time have been lengthened. After knee arthroplasty spatiotemporal parameters have been improved slightly. Conclusions: Before knee arthroplasty patients have unsettled gait pattern, which has slightly changed after operation. This is probably the result of compensatory gait mechanism which has arosen before knee arthroplasty due to pain ailments

Observational studies on ultrasound screening for developmental dysplasia of the hip in newborns - a systematic review

Developmental Dysplasia of the Hip CPG

AIM: To assess whether observational studies provide evidence to support general ultrasound screening for developmental dysplasia of the hip (DDH). METHOD: Systematic Review. Following a predefined study protocol, observational studies on ultrasound screening in unselected newborns were identified by search through 23 electronic databases and by hand search. Two reviewers selected the studies independently of each other and extracted the data. RESULTS: 49 observational studies were included. The prevalence of DDH ranged from 0.5 % to 30 % depending largely on the various possible definitions of DDH. Less than 0.1 % of patients with DDH were missed by ultrasound regardless of the technique employed (Graf or Terjesen). About 90 % of newborns with Graf type IIa hips requiring ultrasound control did not develop DDH. Only six studies with 23 108 newborns reported on complications, and there was only one infant with an avascular necrosis of the femoral head. The effectiveness of a general ultrasound screening cannot be evaluated reliably for several reasons: reports were often incomplete, follow-up of newborns with normal findings at the time of screening was often not carried out, clinically meaningful data about outcome as well as control groups were missing. CONCLUSION: General ultrasound screening for developmental dysplasia of the hip cannot be sufficiently assessed by the observational studies available. The lack of evidence does not mean that ultrasound screening is ineffective, but randomized controlled trials comparing the effectiveness of different screening regimens are needed

Methylmethacrylate as an adjunct in the internal fixation of intertrochanteric fractures of the femur

Management of Hip Fractures in the Elderly

Twenty-eight unstable four-part intertrochanteric fractures in 27 elderly patients with severely osteoporotic femurs were treated by means of internal fixation (commonly the 130 or 95 A.O. blade plate) in combination with methylmethacrylate. Of the 28, ten patients with eleven fractures were recalled and reexamined; 12 had died; five were lost to followup (1 1/2-8 1/2 years) at the time of this review but sufficient documentation existed for their inclusion. There were no deep wound infections. We did not encounter any hypotension during surgery or as a result of the methylmethacrylate. One patient developed a pulmonary embolus 5 days postoperation and responded well to anticoagulant therapy. There were three failures; one femoral shaft fracture at the plate end, one nonunion, both requiring total hip replacemens, and the third failure was due to malreduction of fracture and was later revised. Where bone fragments were in contact, union occurred rapidly and the presence of cement did not interfere with bone union in any way. The patients were pain free and began full weight bearing the day after surgery

The results of fresh-frozen patellar tendon allografts for chronic anterior cruciate ligament deficiency of the knee

Anterior Cruciate Ligament Injuries CPG

This prospective study was done to evaluate the clinical outcome of fresh-frozen patellar bone-tendon-bone allograft tissue used as a substitute for chronic insufficiency of the anterior cruciate ligament. Forty-one patients were followed at a mean of 27 months after surgery. The mean time from injury to reconstruction was 34 months. The same operative procedure and postoperative rehabilitation was performed on each patient. The evaluation method consisted of subjective, objective, and instrumented laxity testing. Thirty-seven patients (90%) thought their knee was normal or improved after surgery and had no further episodes of giving way. The combined modified Hughston Knee Score revealed 30 patients (73%) with an excellent or good result and 9 patients (22%) with a fair or poor result. The mean postoperative Lysholm Knee Score was 91 (range, 56 to 100). Thirty-two had a negative pivot shift (78%). The postoperative KT-1000 arthrometer revealed 37 patients had an injured-to-uninjured difference of 5 mm or less (mean, 1.32 mm; range, 0 to 5). There were three traumatic failures at 24 months postoperatively in this group. There was no rejection phenomenon noted postoperatively. In addition, clinical observation showed less postoperative morbidity when compared to a matched autogenous patellar tendon control group

The nerve/tunnel index: a new diagnostic standard for carpal tunnel syndrome using sonography: a pilot study

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

OBJECTIVES: To define the relationship between body indices of healthy adults and cross-sectional areas of the carpal tunnel and median nerve and to obtain the nerve/tunnel index, which represents a new standard for diagnosing carpal tunnel syndrome using sonography. METHODS: Body indices (height, weight, and body mass index) were analyzed in 60 healthy adults, and electromyography and sonography were also performed. The cross-sectional areas of the proximal and distal median nerve and carpal tunnel were obtained by sonography. The proximal and distal nerve/tunnel indices were obtained by calculating the ratio between the proximal and distal cross-sectional areas of the median nerve to those of the carpal tunnel and multiplying the value by 100. RESULTS: Although the proximal cross-sectional areas of the median nerve and body indices showed statistically significant relationships with weak positive correlations, the proximal and distal areas of the carpal tunnel showed relatively stronger correlations with body indices. Between sexes, there were significant differences in the proximal median nerve cross-sectional area (mean +/- SD: male, 10.48 +/- 3.21 mm(2); female, 8.81 +/- 3.21 mm(2); P < .05) and proximal carpal tunnel area (male, 182.50 +/- 21.15 mm(2); female, 151.23 +/- 21.14 mm(2); P < .05). There was no difference in the proximal nerve/tunnel index (male, 5.80% +/- 1.72%; female, 5.91% +/- 1.63%). There was a statistically significant difference in the distal carpal tunnel cross-sectional area (male, 138.90 +/- 20.95 mm(2); female, 121.50 +/- 18.99 mm(2); P < .05) between sexes, but the distal median area (male, 9.99 +/- 3.42 mm(2); female, 8.46 +/- 1.84 mm(2)) and distal nerve/tunnel index (male, 7.15% +/- 2.00%; female, 7.01% +/- 1.38%) showed no significant differences. The proximal index was significantly higher than the distal index (proximal, 5.85% +/- 1.66%; distal, 7.08% +/- 1.71%). CONCLUSIONS: The nerve/tunnel index is unaffected by body indices or sex and thus may be a useful and objective standard for diagnosing carpal tunnel syndrome

Osteonecrosis of the jaw associated with pamidronate therapy

MSTS 2018 - Femur Mets and MM

Bisphosphonates are commonly used in the treatment and prevention of osteoporosis, and they are also an important therapeutic adjunct in multiple myeloma and other cancers metastatic to bone. Bisphosphonates are generally well tolerated and associated with minimal adverse effects; however, there exists a growing concern that intravenous bisphosphonate use is associated with osteonecrosis of the jaw (ONJ). We report the occurrence of osteonecrosis of the jaw associated with pamidronate therapy in 12 patients diagnosed with multiple myeloma, breast carcinoma, or renal cell carcinoma, all involving bone. At the onset of jaw osteonecrosis, pamidronate therapy was the single medication common to all 12 patients. The duration of therapy varied from 12 to 77 months before osteonecrosis was observed; 92% (11/12) of cases involved the posterior mandible and all cases have been refractory to a variety of medical therapies, including surgical debridement and systemic antibiotics. Available tissue biopsies revealed inflammation consistent with osteomyelitis. In one biopsy, Actinomyces spp. were recovered from culture, but treatment with an extended course of clindamycin conferred no clinical benefit. The persistence of exposed bone remains a significant source of morbidity and pain for each surviving patient. Discontinuation of pamidronate therapy has not helped reverse the presence of osteonecrosis, and surgical manipulation of the involved site appears to worsen the underlying bone pathology. ONJ is an important adverse outcome associated with bisphosphonate therapy, and physicians prescribing pamidronate or zoledronate must be aware of the association between these drugs and this serious clinical entity. Failure to recognize the signs of ONJ can lead to unnecessary surgical procedures, which ultimately exacerbate the condition and impact quality of life. The unremitting nature of this clinical development, and the long-lasting morbidity associated with it suggests that patients should be counseled regarding the possible occurrence of ONJ prior to initiating therapy with pamidronate.

Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing

PJI DX Updated Search

We studied 80 patients (56 females) with an average age of 84 years (range 80-94). All patients were suffering from osteoporosis (1 or 2 Singh score) and had an unstable intertrochanteric fracture, defined as a fracture with three fragments or more. Patients were divided in group A (40 patients), treated by a cement augmentation technique and group B (40 patients) treated by Gamma Nail conventional technique. Augmentation was performed with MetilMetacrilate (Mendec Spine, Tecres) inserted through the cannulated cephalic screw at its apex. Such parameters were evaluated as the length of operating time, early functional recovery using the Harris hip score, assessment with radiography of the TAD index and development of implant related complications. The HHS average score was 48.2 and 49.31 after 1 month post-operation, 54.37 and 53.56 after 3 months, 54.71 and 56.42 after 6 months, 57.91 and 59.86 after 12 months, in groups A and B, respectively. The average drop of haemoglobin was 1.55 g/dL and 1.05 g/dL, in groups A and B, respectively. Except one joint penetration with the guide wire and some small amount of cement leakage, no other complications (infection, screw cut out and femoral head necrosis) were observed. We believe that in femoral intertrochanteric fractures cement augmentation could improve the mechanical stability of the implant, ensuring early functional recovery

A scoping review of strategies for the prevention of hip fracture in elderly nursing home residents

Management of Hip Fractures in the Elderly

BACKGROUND: Elderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear. OBJECTIVE: We performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes. METHODS: We searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate. FINDINGS: We reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7--vitamin D (n = 12,875 participants), 2--sunlight exposure (n = 522), 1--alendronate (n = 327), 1--fluoride (n = 460), 4--exercise or multimodal interventions (n = 8,165), and 5--hip protectors (n = 2,594). Vitamin D, particularly vitamin D(3) > or = 800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC. CONCLUSIONS: The intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed

Systematic Review of Radiofrequency Ablation for Management of Knee Pain

OAK 3 - Non-arthroplasty tx of OAK

Purpose of Review: Chronic pain of the lower extremity remains challenging to manage. Radiofrequency ablation procedure applies heat to nerve fibers with the goal of mitigating chronic pain conditions of the knee. However, the clinical efficacy has not yet been adequately established. The goal of this review paper is to report the use of radiofrequency ablations in the treatment of osteoarthritis of the knee. Recent Findings: PubMed and the Cochrane Controlled Trials Register were searched (final search 28 February 2018) using the MeSH terms â??radiofrequency ablation,â? â??neurolysis,â? â??radiofrequency therapy,â? â??pain syndrome,â? â??analgesia,â? and â??painâ? in the English literature. Bibliographies of the published papers were screened for relevance to lower extremity radiofrequency ablation therapies. The quality of selected publications was assessed using the Cochrane risk of bias instrument. Of the 923 papers screened, 317 were further investigated for relevance. Our final search methodology yielded 19 studies that investigated the use of radiofrequency ablation at the knee. Of these 19 studies, there were four randomized control trials, two non-randomized control trials, three prospective studies, two retrospective studies, one case-control study, one technical report, and seven case reports. Summary: In summary, the data available suggests radiofrequency ablation as a promising and efficacious with all 19 studies revealing significant short- and long-term pain reductions in patients with knee pain.

Topical application of tranexamic acid in primary total hip arthroplasty: A systemic review and meta-analysis

DoD SSI (Surgical Site Infections)

Objective: A systematic review of randomized controlled trials (RCTs) and non-RCTs was performed to evaluate efficacy for the reduction of postoperative blood loss and transfusion requirements of topical use of tranexamic acid in patients undergoing primary total hip arthroplasty. Method: Potential articles were identified from Medline (1966 - September 2014), Embase (1980 - September 2014), Pubmed (1980 - September 2014) and The Cochrane Central Register of Controlled Trials. Other internet databases are also searched to find trials according to the Cochrane Collaboration guidelines. Moreover, gray literatures are also selected from the reference list of the included studies. High quality randomized controlled trials (RCTs) and non-RCTs were selected. The software RevMan 5.1 was used for the mate-analysis. Results: Four RCTs and four non-RCT meet the inclusion criteria. There were significant differences in hemoglobin, total blood loss, transfusion requirements and postoperative drainage volume between TXA groups and control groups. There were no significant differences in length of stay, incidence of wound infection, deep vein thrombosis (DVT) and pulmonary embolism (PE) between treatment and control groups. Conclusions: Present meta-analysis indicates that the antifibrinolytic agent, also known as tranexamic acid, could reduce hemoglobin decline, volume of drainage, total blood loss and transfusion requirements after THA, and is not related to adverse reactions or complications such as wound infection, DVT and PE.

Changes in Bone Marrow Lesions Following Root Repair Surgery Using Modified Mason-Allen Stitches in Medial Meniscus Posterior Root Tears

AMP (Acute Meniscal Pathology)

Root repair can prevent osteoarthritis (OA) by restoring hoop tension in medial meniscus posterior root tears (MMPRTs). This study aims to investigate bone marrow edema (BME) lesions known to be associated with OA following MMPRTs. <b>Methods</b>: Thirty patients with transtibial pull-out repair were recruited. Subchondral BME lesions were evaluated using magnetic resonance imaging (MRI) at 1-year follow-ups. Participants were categorized into three groups: no change of BME lesions (group one), improved BME lesions (group two) and worsened BME lesions (group three). Clinical scores and radiological outcomes, specifically Kellgren-Lawrence grade, medial joint space width and cartilage grade and meniscal extrusion were evaluated and compared between groups. <b>Results</b>: After surgery, twenty-three patients with no BME, three patients with BME lesions on the medial femoral condyle, one patient with BME lesions on the medial tibia plateau and three patients with BME lesions on both were investigated. A total of 20 patients in group one (66.7%) showed no change in BME lesions. In group two, seven patients (23.3%) presented with improved BME lesions. Only three patients (10%) showed worsened BME lesions (group three). Moreover, Lysholm scores and the rate of progression of cartilage grades were significantly worse in group three patients. Meniscal extrusion was significantly reduced in group two, whereas extrusion was significantly progressed in group three. <b>Conclusion</b>: Patients with worsened BME lesions showed less favorable outcomes than other patients. A decrease in meniscal extrusion can have a positive effect on BME lesions after root repair.

Need of Revision of Lower Limb Amputations in a North Indian Tertiary Care Centre

DoD LSA (Limb Salvage vs Amputation)

INRTODUCTION: Amputation of the extremity is a big challenge to mankind. Revision rate of primary amputations stands high despite of maximum care at tertiary care centres. The purpose of this study was to establish cause for the revision, identify preventable cause and to assess outcome of revision amputation surgery. MATERIALS AND METHODS: We performed a retrospective study on lower limb revision amputations in Department of Physical Medicine and Rehabilitation and Department of Orthopaedic Surgery, King George Medical University between Jan 2012 to Jan 2015. All patients of any age group and gender admitted for revision amputation were included in the study population. RESULTS: A total of 32 patients who required revision amputation of lower limbs was included in the study, out of these 62.50 % were male and 37.50 % were female. Age of the patients ranged from 5 to 72 years with mean of 42 years. Most common level of initial amputation was below knee (56.25 %) followed by above knee amputation (31.25%). Most common indication for initial amputation was trauma (43.75%) followed by infection, vascular diseases, malignancy and leprosy. Poor stump formation was found to be most common indication for revision amputation (37.50%) followed by infection (25%), recurrent ulceration (18.75%), stitch abscess (6.25%), neuroma (6.25%), and necrosis (6.25%). All patients were treated successfully. CONCLUSION: Revision amputation increases morbidity. Poor stump formation at the time of initial amputation and infection are the most common indication for revision surgery. These are the preventable causes and every effort should be made to alleviate these as well as other preventable causes.

KNOWLEDGE GAPS IN ORAL AND MAXILLOFACIAL SURGERY: A SYSTEMATIC MAPPING

Dental Implant Infection

OBJECTIVES: The aim of this study was to evaluate available knowledge and identify knowledge gaps within the field of oral and maxillofacial surgery, by systematically collecting and evaluating systematic reviews. Twelve specific domains were selected: surgical removal of teeth, antibiotic and corticosteroid prophylaxis, orofacial infections, dental and facial trauma, orthognathic surgery, reconstructive surgery, benign tumors, cysts, premalignant lesions, oral complications of treatment of malignant tumors, hyperbaric oxygen therapy, temporomandibular joint surgery, cost effectiveness of different surgical treatments, and ethics., METHODS: The literature search, covering four databases, was conducted during September 2014: PubMed, The Cochrane library, Centre for Reviews and Dissemination and EBSCO dentistry and oral science source. Retrieved systematic reviews were quality assessed by AMSTAR., RESULTS: In all, 1,778 abstracts were identified, of which 200 met the inclusion criteria. Forty-five systematic reviews were assessed as of high to moderate quality. The results disclosed some existing evidence in a few domains, such as surgical removal of teeth and implant survival after sinus lifts. However, in all domains, the search revealed a large number of knowledge gaps. Also of concern was the lack of data regarding health economics and ethics., CONCLUSIONS: In conclusion, there is a need for well-conducted clinical research in the fields of oral and maxillofacial surgery.

"'Timed up and go' test and bone mineral density measurement for fracture prediction

Management of Hip Fractures in the Elderly

BACKGROUND: Two major factors associated with skeletal fracture in older persons are intrinsic bone strength and risk of falling. This study examined the role of Timed Up and Go (TUG) test performance, a validated predictor of falling, and hip areal bone mineral density (BMD), a validated predictor of bone strength in fracture prediction in a 10-year longitudinal study. METHODS: The study participants were 1126 women (mean [SD] age at baseline, 75.0 [2.6] years) living in Perth, Western Australia. Assessments included TUG test at baseline and dual-energy x-ray absorptiometry total hip areal BMD measurement at year 1. Incident clinical osteoporotic fracture over 10 years was confirmed by radiographic records. Complete incident hip fracture data were obtained from a hospital morbidity database. RESULTS: One-third (32.7%) of participants had slow TUG test performance (>10.2 seconds), and 54.2% of participants had low hip areal BMD (T-score of less than -1). Relative to risks among participants having normal TUG test performance and normal BMD, risks of nonvertebral fracture and hip fracture were significantly higher among participants who had slow TUG test performance and normal hip BMD (nonvertebral fracture hazard ratio [HR], 1.84; hip fracture HR, 2.48) or both slow TUG test performance and low hip BMD (nonvertebral fracture HR, 2.51; hip fracture HR, 4.68). For nonvertebral fracture and hip fracture, the population-attributable risks of slow TUG test performance with normal hip BMD were 19.3% and 32.3%, of normal TUG test performance with low hip BMD were 31.3% and 50.3%, and of both slow TUG test performance and low hip BMD were 30.1% and 55.9%, respectively. CONCLUSION: TUG test performance is an independent risk factor for incident nonvertebral fracture and a feasible inexpensive physical performance assessment for use in clinical practice to screen patients with increased risk of fracture

The case for the metal-backed glenoid design in total anatomical shoulder arthroplasty

Glenohumeral Joint OA

After 38 years of unchallenged reign of cemented full polyethylene glenoid implants, the main problem of anatomical shoulder arthroplasty is still glenoid loosening, also the main cause of failure. A certain concern regarding uncemented metal back components in total anatomical shoulder arthroplasty has developed, due to problems evoked in the literature. This work is a comprehensive bibliographical review of the different clinical and biomechanical studies of noncemented glenoid implants. Those publications often showed a high rate of failure of uncemented glenoid implants, but their arguments appeared often theoretical or based on old and/or nonadapted devices. In conclusion, the authors emphasise that research on new designs of metal back components needs to go on. © 2011 Springer-Verlag.

Glass foreign bodies inside the knee joint following intra-articular injection

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: Foreign bodies inside the knee joint are not uncommon. However, the literature has no reports of a foreign body inside the knee joint, with no history of trauma. CASE REPORT: Glass foreign bodies were found embedded inside the knee joint during arthroscopic washout for a middle aged male patient with knee osteoarthritis. The patient had no history of trauma and no scars or sign of entry of foreign bodies. It was found that these foreign bodies originated from glass vials broken while withdrawing medication for intra-articular injection of this knee in the past. CONCLUSIONS: To avoid similar incidents, the authors recommend using filter needles to withdraw medications from glass vials.

Postoperative analgesia and functional recovery after total-knee replacement: comparison of a continuous posterior lumbar plexus (psoas compartment) block, a continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND AND OBJECTIVES: Continuous femoral nerve block is a well-accepted technique for regional analgesia after total-knee replacement. However, many patients still experience considerable pain at the popliteal space and at the medial aspect of the knee. The goal of this study is to evaluate whether a psoas compartment catheter provides better postoperative analgesia than a femoral nerve catheter does and whether it is as effective as the combination of a femoral and a sciatic nerve catheter and, thus, improves functional outcome. METHODS: Ninety patients who underwent total-knee replacement under standardized general anesthesia participated in this prospective randomized study. Group FEM received a continuous femoral nerve block, group FEM/SCI received a combination of a femoral and a sciatic continuous nerve block, and group PSOAS received a continuous psoas compartment block. Patient-controlled analgesia with piritramide was available for 48 hours. Maximal bending and extending of the knee and walking distance was assessed during the first 7 days. A standardized telephone survey was conducted after 9 to 12 months to evaluate residual pain and functional outcome. RESULTS: Postoperative opioid consumption during 48 hours was significantly less in the FEM/SCI group (median: 18 mg; 25th/75th percentile: 6/40) compared with the FEM group (49 mg; 25/66) and the PSOAS group (44 mg; 30/62) (P =.002). Postoperative pain scores were not different, and no differences occurred with respect to short-term or long-term functional outcome. CONCLUSION: The FEM/SCI catheter is superior to FEM and PSOAS catheter with respect to reduced analgesic requirements after total-knee replacement, but functional outcome does not differ with those 3 continuous regional analgesia techniques

Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

OAK 3 - Non-arthroplasty tx of OAK

BACKGROUND: In total knee arthroplasty, both intravenous (IV) and intra-articular (IA) administration of tranexamic acid (TXA) have been shown to reduce blood loss in several randomized controlled trials, although routine use of systemic TXA is considerably more common. However, to our knowledge, the additional benefit of IA administration of TXA when combined with IV administration, without the use of a tourniquet, has not been previously investigated. Thus, the aim of this study was to evaluate whether combined IV and IA administration of TXA reduced total blood loss compared with IV-only administration of TXA. METHODS: In this randomized, double-blind, placebo-controlled trial, 60 patients scheduled for total knee arthroplasty were randomized to one of two interventions. The TXA IV and IA group received combined administration of TXA consisting of 1 g administered intravenously preoperatively and 3 g diluted in 100 mL of saline solution administered intra-articularly after closure of the capsule. The TXA IV and placebo group received 1 g of TXA administered intravenously only and 100 mL of saline solution administered intra-articularly. IA TXA was administrated through a needle. The primary outcome was the 24-hour calculated blood loss. Secondary outcomes were blood loss on postoperative day 2, thromboembolic complications, and transfusion rate. Blood loss was calculated by hemoglobin differences using the Gross formula. RESULTS: Data on the primary outcome were available for all 60 included patients. Baseline characteristics were comparable between the allocation groups. The mean 24-hour blood loss (and standard deviation) was 466 +/- 313 mL in the TXA IV and IA group compared with 743 +/- 358 mL in the TXA IV and placebo group; treatment effect (difference), 277 mL (95% confidence interval [CI], 103 to 451 mL) (p = 0.002). Second-day blood loss was 644 +/- 382 mL in the TXA IV and IA group compared with 1017 +/- 519 mL in the TXA IV and placebo group; treatment effect, 373 mL (95% CI, 132 to 614 mL) (p = 0.003). No thromboembolic complications were observed within 90 days postoperatively. CONCLUSIONS: The combined administration of IV and IA TXA resulted in a clinically relevant reduction in blood loss of 37% compared with IV TXA alone both at 24 hours postoperatively and on postoperative day 2. No thromboembolic complications were observed. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Convolutional neural networks for automated fracture detection and localization on wrist radiographs

Distal Radius Fractures

Purpose: To demonstrate the feasibility and performance of an object detection convolutional neural network (CNN) for fracture detection and localization on wrist radiographs. Materials and Methods: Institutional review board approval was obtained with waiver of consent for this retrospective study. A total of 7356 wrist radiographic studies were extracted from a hospital picture archiving and communication system. Radiologists annotated all radius and ulna fractures with bounding boxes. The dataset was split into training (90%) and validation (10%) sets and used to train fracture localization models for frontal and lateral images. Inception-ResNet Faster R-CNN architecture was implemented as a deep learning model. The models were tested on an unseen test set of 524 consecutive emergency department wrist radiographic studies with two radiologists in consensus as the reference standard. Per-fracture, per-image (ie, per-view), and per-study sensitivity and specificity were determined. Area under the receiver operating characteristic curve (AUC) analysis was performed. Results: The model detected and correctly localized 310 (91.2%) of 340 and 236 (96.3%) of 245 of all radius and ulna fractures on the frontal and lateral views, respectively. The per-image sensitivity, specificity, and AUC were 95.7% (95% confidence interval [CI]: 92.4%, 97.8%), 82.5% (95% CI: 77.4%, 86.8%), and 0.918 (95% CI: 0.894, 0.941), respectively, for the frontal view and 96.7% (95% CI: 93.6%, 98.6%), 86.4% (95% CI: 81.9%, 90.2%), and 0.933 (95% CI: 0.912, 0.954), respectively, for the lateral view. The per-study sensitivity, specificity, and AUC were 98.1% (95% CI: 95.6%, 99.4%), 72.9% (95% CI: 67.1%, 78.2%), and 0.895 (95% CI: 0.870, 0.920), respectively. Conclusion: The ability of an object detection CNN to detect and localize radius and ulna fractures on wrist radiographs with high sensitivity and specificity was demonstrated.

Operative Intervention of Supracondylar Humerus Fractures More Complicated in July: Analysis of the July Effect

Pediatric Supracondylar Humerus Fracture 2020 Review

BACKGROUND: The "July Effect" involves the influx of new interns and residents early in the academic year (July and August), which may have greater potential for poorer patient outcomes. Current orthopaedic literature does not demonstrate the validity of this concept in arthroplasty, spine, hand, and arthroscopy. No study has investigated the possibility of this effect on common pediatric orthopaedic procedures, such as closed reduction and percutaneous pin fixation of supracondylar humerus fractures. METHODS: A retrospective review of all type II or III supracondylar humerus fractures that underwent primary closed reduction and percutaneous pin fixation (CPT code 24538) at a single pediatric level 1 trauma center from July 2009 to June 2013. Patients were grouped according to time in the academic year: early (July and August) and late (May and June). Demographic data included length of follow-up, age at surgery, sex, side of injury, and Wilkin's modified Gartland classification. Outcomes included length of operation, number of pins used, length of stay, complications, and the need for repeat surgery. RESULTS: There were 245 patients, 101 in the early and 144 in the late group. There was no increase in surgical time [33.32±24.74 (early) vs. 28.63±10.06 (late) min, P=0.07) or complication rates [7.0% (early) vs. 2.1% (late), P=0.06) between the early and the late groups. Cases performed with junior residents demonstrated longer operative (31.72±17.07 vs. 28.96±18.71 min, P=0.02) and fluoroscopy (48.63±30.96 vs. 34.12±27.38 s, P=0.01) times. CONCLUSIONS: The academic orthopaedic surgeon must ensure the education of residents, while providing the highest level of safety to patients. Our study shows that education of young residents early in the academic year results in no increase in operative times, radiation exposure, or complications. LEVEL OF EVIDENCE: Level III.

Hospital case volume and outcomes for proximal femoral fractures in the USA: an observational study

Hip Fx in the Elderly 2019

OBJECTIVE: To explore whether older adults with isolated hip fractures benefit from treatment in high-volume hospitals. DESIGN: Population-based observational study. SETTING: All acute hospitals in California, USA. PARTICIPANTS: All individuals aged >=65 that underwent an operation for an isolated hip fracture in California between 2007 and 2011. Patients transferred between hospitals were excluded. PRIMARY AND SECONDARY OUTCOMES: Quality indicators (time to surgery) and patient outcomes (length of stay, in-hospital mortality, unplanned 30-day readmission, and selected complications). RESULTS: 91,401 individuals satisfied the inclusion criteria. Time to operation and length of stay were significantly prolonged in low-volume hospitals, by 1.96 (95% CI 1.20 to 2.73) and 0.70 (0.38 to 1.03) days, respectively. However, there were no differences in clinical outcomes, including in-hospital mortality, 30-day re-admission, and rates of pneumonia, pressure ulcers, and venous thromboembolism. CONCLUSIONS: These data suggest that there is no patient safety imperative to limit hip fracture care to high-volume hospitals.

Timing, Sites, and Correlates of Lung Cancer Recurrence

MSTS 2022 - Metastatic Disease of the Humerus

Introduction: Understanding temporal and anatomic patterns of lung cancer recurrence could guide disease management and monitoring. However, these data are not available in population-based datasets and are not routinely recorded in clinical trials. Materials and Methods: We identified cases of stage 1 to 3 lung cancer diagnosed January 1, 2000, to December 31, 2017, in the tumor registry of a National Cancer Institute-designated comprehensive cancer center. For cases with documented disease recurrence, we recorded anatomic site(s) and timing. We estimated time to recurrence using Kaplan-Meier methods. Associations between case characteristics and recurrence features were assessed using univariable and multivariable logistic regression models and Cox regression models. Results: A total of 1619 cases of stage 1 to 3 lung cancer from 1549 patients were included in the analysis. Of these, 466 (30%) patients developed recurrent lung cancer. The most common type of first recurrence was distant disease, most commonly central nervous system (CNS) (37%). In multivariable analyses, race (P = .02) and primary treatment modality (P < .001) correlated with recurrent disease, whereas tumor histology (P = .004) and primary treatment modality (P < .001) were associated specifically with distant recurrence. Patient age (P = .05) and initial TNM stage (P = .001) correlated with timing of recurrence. Conclusion: In this single-center series of stage 1 to 3 lung cancer, recurrent disease was associated with race, histology, and treatment modality, and most commonly occurred in the CNS. Modulation of clinical and radiographic disease monitoring according to recurrence risk, timing, and site may offer a means to identify future lung cancer when it remains asymptomatic and highly treatable.

Prognostic impact of chronological age on efficacy of immune checkpoint inhibitors in non-small-cell lung cancer: Real-world data from 86 173 patients

MSTS 2022 - Metastatic Disease of the Humerus

Immune checkpoint inhibitors (ICIs) have become standard pharmacological therapies in patients with non-small-cell lung cancer (NSCLC). Because elderly patients with NSCLC are often excluded from clinical trials as a result of lower functional capacity or comorbidities, the prognostic impact of chronological age on the efficacy of ICIs is unclear. The National Cancer Database was queried for stage IV NSCLC patients between 2014 and 2015. Associations between ICI therapy and clinical characteristics were assessed using chi-squared tests. Kaplan–Meier curves were compared using the log-rank test. A Cox proportional hazards model was used to identify clinical characteristics predictive of overall survival (OS). This study included 24 136 patients with stage IV NSCLC aged =75 years and 62 037 patients with stage IV NSCLC aged <75 years. Patients aged =75 years treated with ICIs had significantly longer OS than those not treated with ICIs (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.58–0.64, p < 0.0001). The corresponding HR in patients aged <75 years was 0.67 (95% CI 0.65–0.68, p < 0.0001). Cox modeling confirmed the survival benefit of ICI therapy in patients aged =75 years (HR for patients not receiving ICIs 1.63 [95% CI: 1.55–1.71], p < 0.0001). The corresponding HR in patients aged <75 years was 1.47 (95% CI 1.43–1.51, p < 0.0001). Chronological age does not appear to negatively impact the survival benefit of ICI therapy in patients with stage IV NSCLC according to this large real-world database analysis.

Effect of postoperative delirium on outcome after hip fracture

Hip Fx in the Elderly 2019

Nine-hundred twenty-one community-dwelling patients 65 years of age or older, who sustained an operatively treated hip fracture from July 1, 1987 to June 30, 1998 were followed up for the development of postoperative delirium. The outcomes examined in the current study were postoperative complication rates, in-hospital mortality, hospital length of stay, hospital discharge status, 1-year mortality rate, place of residence, recovery of ambulatory ability, and activities of daily living 1 year after surgery. Forty-seven (5.1%) patients were diagnosed with postoperative delirium. Patients who had delirium develop were more likely to be male, have a history of mild dementia, and have had surgery under general anesthesia. Patients who had postoperative delirium develop had a significantly longer length of hospitalization. They also had significantly higher rates of mortality at 1 year, were less likely to recover their prefracture level of ambulation, and were more likely to show a decline in level of independence in basic activities of daily living at the 1-year followup. There was no difference in the rate of postoperative complications, in-hospital mortality, discharge residence, and recovery of instrumental activities of daily living at 1 year.

Anatomic variations of the median nerve in carpal tunnel release

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Carpal tunnel syndrome (CTS) is a well-known clinical entity. Release of the transverse carpal ligament is considered to be the treatment of choice. Both open and endoscopic release of the transverse carpal ligament in CTS has yielded satisfactory results. Although these procedures are very common in surgical practice, inadequate release and intraoperative damage to neural elements are very frustrating complication for both the patient and the surgeon. The purpose of this study was to demonstrate incidental intraoperative findings of variations of the standard median nerve anatomy. We obtained incidental intraoperative identification of median nerve variations in 110 consecutive patients operated with open release of the transverse carpal ligament in CTS. Using the Amadio classification, we found intraoperatively variations of median nerve at the wrist in 11 patients. In three patients, there was an aberrant sensory branch arising from the ulnar side of the median nerve and piercing the ulnar margin of the transverse carpal ligament. Neural variations arising from the ulnar aspect of the median nerve were common and could be a cause of iatrogenic injury during endoscopic or open release. Surgeons should be aware of anomalous branches, which should be recognized and separately decompressed if needed

Explanatory style as a risk factor for traumatic mishaps

DoD PRF (Psychosocial RF)

Six studies investigated a possible link between hopeless explanatory style--that is, the habitual explanation of bad events with stable and global causes--and risk for traumatic injuries. In samples of college students, dancers, athletes, and trauma patients (total n=2,274), stable and global explanations for bad events correlated with the occurrence of mishaps. The link appeared to be mediated in part by a preference for potentially hazardous settings and activities in response to negative moods associated with hopelessness. Taken together, these findings suggest that catastrophizing individuals may be motivated to escape negative moods by preferring exciting but risky courses of action. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Meniscal allografts: biomechanics and techniques

AMP (Acute Meniscal Pathology)

Arthroscopic partial meniscectomy is one of the most common orthopedic surgical procedures performed. Numerous clinical and biomechanical studies have shown the long-term consequences of the meniscus-deficient knee, which includes increased loading of the cartilage. This leads to chondromalacia, and ultimately pain and dysfunction. Few treatment options are available for the young patient with pain in the tibiofemoral compartment secondary to meniscus deficiency. Meniscal allograft transplantation is a viable treatment option in this group of patients as short-term results have shown pain relief and functional improvement. Biomechanical studies have shown that the allograft meniscal transplant functions most like a native, intact meniscus when specific surgical principles are followed. Surgical techniques for meniscal allograft transplantation have advanced along with instrumentation. An improvement in function and pain relief can be expected when strict criteria are followed in patient selection and surgical technique. [References: 59]

Erratum: Effect of addition of dexmedetomidine to ropivacaine 0.2% for femoral nerve block in patients undergoing unilateral total knee replacement: A randomised double blind study (Indian Journal of Anaesthesia, (2016) 60, 6,(403-408))

AAHKS (8) Anesthetic Infiltration

In the article titled, â??Effect of addition of dexmedetomidine to ropivacaine 0.2% for femoral nerve block in patients undergoing unilateral total knee replacement: A randomised double blind study.â? published in pages 403-408, issue 6, vol. 60 of Indian Journal of Anaesthesia[1], the affiliation of the first author â??Bhawana Sharmaâ? is written incorrectly as â??Department of Anaesthesia, Maulana Azad Medical College, New Delhiâ? instead of â??Department of Anaesthesia, University College of Medical Sciences and GTB Hospital, Delhiâ?. This has now been corrected and reposted online.

Safety of Aesthetic Surgery in the Overweight Patient: Analysis of 127,961 Patients

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Nearly 70% of US adults are overweight or obese (body mass index, BMI >/= 25 kg/m(2)), and more such patients are seeking aesthetic surgery. Previous studies have evaluated surgical risk in obese (BMI >/= 30) or morbidly obese (BMI >/= 40) patients, with mixed results. OBJECTIVES: This study evaluates BMI 25 to 29.9 and BMI >/= 30 as independent risk factors of major complications following aesthetic surgery in a large, prospective, multi-center database. METHODS: A prospective cohort of patients undergoing aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database (Birmingham, AL). BMI was evaluated as a risk factor for major complications, defined as complications requiring an emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Multivariate analysis controlled for variables including age, gender, smoking, diabetes, combined procedures, and type of surgical facility. RESULTS: Of the 127,961 patients, 36.2% had BMI >/= 25. Overweight patients were more likely to be male (12.5%), diabetic (3.3%), nonsmokers (92.8%), or have multiple procedures (41%). Complication rate steadily increased with BMI: 1.4% (BMI < 18.5); 1.6% (18.5-24.9); 2.3% (25-29.9); 3.1% (30-39.9); 4.2% (>/=40). Infection (0.8%), venous thromboembolism (VTE, 0.4%), and pulmonary dysfunction (0.2%) were twice as common among overweight patients. Incidence of hematoma was similar in the two groups (0.9%). Complications following abdominoplasty (3.5%), liposuction (0.9%), lower body lift (8.8%), or combined breast and body procedures (4.2%) were significantly higher in overweight patients. On multivariate analysis, being overweight (BMI 25-29.9) or obese (BMI >/= 30) were independent predictors of any complication (Relative Risk, RR 1.17 and 1.51), especially infection (RR 1.63 and 2.73), and VTE (RR 1.67 and 2.56). CONCLUSIONS: Overweight (BMI 25-29.9) and obesity (BMI >/= 30) are both independent risk factors for post-operative infection and VTE in aesthetic surgery. LEVEL OF EVIDENCE 2: Risk.

Mental distress in patients with cerebral visual injury assessed with the german brief symptom inventory

Upper Eyelid and Brow Surgery

BACKGROUND: While there are reports on vision-related quality of life in patients with vision impairment caused by both ophthalmic and brain diseases, little is known about mental distress. In fact, mental distress after cerebral visual injury has been widely ignored. METHODS: Mental health symptoms were assessed in 122 participants with visual field defects after brain damage (72 male, mean age 58.1 +/- 15.6 years), who completed the German Brief Symptom Inventory (BSI) at their homes after they had been asked by phone for their participation. RESULTS: Clinically relevant mental distress was present in 25.4% of participants with cerebral visual injury. In case of multisensory impairment, an increased amount and intensity of mental distress symptoms was observed compared to the subsample with only visual impairment. CONCLUSION: Assessment of comorbid mental health symptoms appears to be clinically meaningful in brain-damaged patients with visual sensory impairment. In case of clinically relevant mental distress, psychological supportive therapies are advisable especially in subjects with cerebral visual injury and comorbidities affecting other sensory modalities as well.

Assessment of menisci and ligamentous injuries of the knee on magnetic resonance imaging: correlation with arthroscopy

Anterior Cruciate Ligament Injuries CPG

OBJECTIVE: To evaluate the validity of MRI, in the assessment of the meniscal and cruciate ligamenteous injuries of the knee joint and comparison with arthroscopic findings. METHODS: A one year prospective cross-sectional study from January 2006 to January 2007, was performed on 50 patients (32 males & 18 females) with knee injury presenting at the orthopedic unit of AKUH. The patients were referred to radiology department for MRI evaluation and arthroscopy. RESULTS: The sensitivity, specificity and accuracy for MRI of the menisci and ligaments were as follows: medial meniscus resulted in 100% sensitivity, 69.27% specificity, 90% PPV, 100% NPV and 92% accuracy: lateral meniscus resulted in 87.5% sensitivity, 88.23% specificity, 77% PPV, 93% NPV and 88% accuracy: anterior cruciate ligament resulted in 86.67% sensitivity, 91.43% specificity, 81% PPV, 94% NPV and 88% accuracy; posterior cruciate ligament resulted in 100% sensitivity, 95.83% specificity,50% PPV, 100 NPV and 96% accuracy. CONCLUSION: Magnetic resonance imaging is a good, accurate and non invasive modality for the assessment of menisci and ligamenteous injuries. It can be used as a first line investigation in patients with soft tissue trauma to knee

As Goes the Meniscus Goes the Knee: Early, Intermediate, and Late Evidence for the Detrimental Effect of Meniscus Tears

AMP (Acute Meniscal Pathology)

The meniscus plays an important, complex role in maintaining the homeostasis and health of the knee. Meniscal tears are a risk factor for early chondral injury and eventually knee osteoarthritis. There is a growing body of evidence about the early biological changes associated with meniscal injury that likely start the process of joint degeneration. This review highlights the basic science, translational and clinical studies of the detrimental effects of meniscal injury and deficiency on the biology of the knee.

Differences in Abuse and Related Risk and Protective Factors by Runaway Status for Adolescents Seen at a U.S. Child Advocacy Centre

DoD PRF (Psychosocial RF)

OBJECTIVES: This study examined the abuse prevalence and characteristics, and risk and protective factors, among both runaway and non-runaway adolescents evaluated at a Child Advocacy Center (CAC) in Minnesota, which had implemented a referral program to assess runaways for potential sexual assault or sexual exploitation. METHODS: A cross-sectional analysis of self-report and chart data for the 489 adolescent girls who were evaluated between 2008 and 2010. Chi-square and t-tests by runaway status compared abuse experiences, trauma responses, health issues, and potential protective assets associated with resilience between runaways and non-runaways. Bivariate logistic regressions explored the relationship of these risk and protective factors to self-harm, suicide attempts, and problem substance use, separately for runaways and non-runaways who had experienced sexual abuse. RESULTS: Runaways were significantly more likely than non-runaways to have experienced severe sexual abuse, to have used alcohol and drugs, and reported problem substance use behavior, higher levels of emotional distress, more sexual partners, and they were more likely to have a sexually transmitted infection (STI). Runaways had lower levels on average of social supports associated with resilience, such as connectedness to school, family or other adults. Yet higher levels of these assets were linked to lower odds of self-harm, suicide attempt and problem substance use for both groups. CONCLUSIONS AND IMPLICATIONS: CACs should encourage referrals of runaway adolescents for routine assessment of sexual assault, and incorporate screening for protective factors in addition to trauma responses in their assessments of all adolescents evaluated for possible sexual abuse, to guide interventions.

Evidence for a selected humoral immune response encoded by VH4 family genes in the synovial membrane of a patient with rheumatoid arthritis (RA)

Surgical Management of Osteoarthritis of the Knee CPG

The analysis of rearranged antibody-encoding genes from B cell foci in rheumatoid synovial tissue has characterized these cells as highly mutated memory B cells with a high proportion of members of the VH4 family. In order to characterize further the VH4 response in one patient, B cell-rich areas from different sections of synovial membrane (SM) were identified by CD20 staining, isolated by microdissection and pooled, in order to analyse highly enriched B cells without selection by in vitro culture procedures. From DNA of about 5 x 10(3) B cells rearranged VH genes were amplified by polymerase chain reaction (PCR) and cloned. Sequencing of 11 clones containing rearranged VH4 gene products revealed that seven were potentially functional, and all were mutated with 84-96% homology to known germ-line (gl) genes and VH4 gl genes amplified from the patient's genomic DNA. Analysis of the complementarity determining region (CDR) 3 revealed that two products represented members of one B cell clone which differed by five nucleotide changes. Three of the five mutations encoded amino acid replacements in CDRs indicating antigen-driven expansion of one specific clone. Additional analyses of 25 members of three B cell clones from isolated aggregates showing intraclonal diversity in one of three clones provided further evidence that antigen selection takes place in the SM. Overall, the pattern of mutations and the replacement to silent (R:S) ratios were diverse, with six products indicating antigen selection by their high R:S ratios in CDRs. Although DNA analysis does not allow a characterization of antibody specificities, we can conclude from our analysis does not allow a characterization of antibody specificities, we can conclude from our analysis of antibody-encoding genes that selection by antigen and expansion of specific clones occur in the SM against the background of polyclonal activation

Injuries and the cost of falls among older adults how pharmacists can help

Management of Hip Fractures in the Elderly

Fall-related injuries are a serious public health issue among older adults. In addition to having a significant impact on our economy, these injuries are associated with considerable morbidity. Each year, 1 out of every 3 adults aged 65 and older fall; of these adults, 10% to 20% sustain serious injuries such as fractures or head traumas. Such injuries account for about 6% of medical expenditures for adults 65 years and older. Pharmacist interventions can prevent falls, thereby improving the quality of life of these older adults, preserving their independence, and significantly reducing health care costs. (copyright) 2009 SAGE Publications

Dyslexia and fluency: parafoveal and foveal influences on rapid automatized naming

Upper Eyelid and Brow Surgery

The ability to coordinate serial processing of multiple items is crucial for fluent reading but is known to be impaired in dyslexia. To investigate this impairment, we manipulated the orthographic and phonological similarity of adjacent letters online as dyslexic and nondyslexic readers named letters in a serial naming (RAN) task. Eye movements and voice onsets were recorded. Letter arrays contained target item pairs in which the second letter was orthographically or phonologically similar to the first letter when viewed either parafoveally (Experiment 1a) or foveally (Experiment 1b). Relative to normal readers, dyslexic readers were more affected by orthographic confusability in Experiment 1a and phonological confusability in Experiment 1b. Normal readers were slower to process orthographically similar letters in Experiment 1b. Findings indicate that the phonological and orthographic processing problems of dyslexic readers manifest differently during parafoveal and foveal processing, with each contributing to slower RAN performance and impaired reading fluency.

Invasive group A Streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation

Panniculectomy & Abdominoplasty CPG

IMPORTANCE: Liposuction is one of the most common cosmetic surgery procedures in the United States. Tumescent liposuction, in which crystalloid fluids, lidocaine, and epinephrine are infused subcutaneously before cannula-assisted aspiration of fat, can be performed without intravenous or general anesthesia, often at outpatient facilities. However, some of these facilities are not subject to state or federal regulation and may not adhere to appropriate infection control practices. OBJECTIVE: To describe an outbreak of severe group A Streptococcus (GAS) infections among persons undergoing tumescent liposuction at 2 outpatient cosmetic surgery facilities not subject to state or federal regulation. DESIGN: Outbreak investigation (including cohort analysis of at-risk patients), interviews using a standardized questionnaire, medical record review, facility assessment, and laboratory analysis of GAS isolates. SETTING AND PARTICIPANTS: Patients undergoing liposuction at 2 outpatient facilities, one in Maryland and the other in Pennsylvania, between July 1 and September 14, 2012. MAIN OUTCOMES AND MEASURES: Confirmed invasive GAS infections (isolation of GAS from a normally sterile site or wound of a patient with necrotizing fasciitis or streptococcal toxic shock syndrome), suspected GAS infections (inflamed surgical site and either purulent discharge or fever and chills in a patient with no alternative diagnosis), postsurgical symptoms and patient-reported experiences related to his or her procedure, and emm types, T-antigen types, and antimicrobial susceptibility of GAS isolates. RESULTS: We identified 4 confirmed cases and 9 suspected cases, including 1 death (overall attack rate, 20% [13 of 66]). One instance of likely secondary GAS transmission to a household member occurred. All confirmed case patients had necrotizing fasciitis and had undergone surgical debridement. Procedures linked to illness were performed by a single surgical team that traveled between the 2 locations; 2 team members (1 of whom reported recent cellulitis) were colonized with a GAS strain that was indistinguishable by laboratory analysis of the isolates from the case patients. Facility assessments and patient reports indicated substandard infection control, including errors in equipment sterilization and infection prevention training. CONCLUSIONS AND RELEVANCE: This outbreak of severe GAS infections was likely caused by transmission from colonized health care workers to patients during liposuction procedures. Additional oversight of outpatient cosmetic surgery facilities is needed to assure that they maintain appropriate infection control practices and other patient protections. Copyright 2014 American Medical Association. All rights reserved.

Adjunctive use of the superficial femoral vein for vascular reconstructions

DOD - Acute Comp Syndrome CPG

Objective: Although the superficial femoral vein (SFV) is an accepted treatment for aortic graft infections, this conduit also has potential uses in other areas. Herein, we evaluate our experience using the SFV for arterial and venous bypasses and the arteriovenous (AV) fistula for dialysis access. Methods: Between 1999 and 2011, 42 patients underwent a bypass or a thigh AV fistula using the SFV (31 arterial, four central venous, six AV fistulas, and one common carotid-to-vertebral bypass). Indications for arterial bypass included infected graft (20), critical limb ischemia (nine), and failed bypass (six). Indications for central venous bypass were: superior vena cava syndrome (two), vessel reconstruction due to tumor encasement (one), and central vein occlusion from thoracic outlet syndrome (one). All AV fistulas were created after patients sustained bilateral subclavian vein occlusions from failed upper extremity access. The common carotid-to-vertebral bypass was created due to an occluded vertebral artery with resultant stroke. Results: Kaplan-Meier cumulative patency curves were used. The primary patency rates at 30 days, 1 year, and 3 years were 97.4% (95% confidence interval [CI], 92.41-100), 74.6% (95% CI, 57.89-96.23), and 66.4% (95% CI, 47.06-93.53), respectively. The assisted primary patency rates at 30 days, 1 year, and 3 years were 100% (95% CI, 100-100), 97.1% (95% CI, 91.54-100), and 89% (95% CI, 74.29-100), respectively. Secondary patency rates at 30 days, 1 year, and 3 years were 100% (95% CI, 100-100), 97.1% (95% CI, 91.54-100), and 89% (95% CI, 74.29-100), respectively. Limb salvage rates at 30 days, 1 year, and 3 years were 97.3% (95% CI, 92.21-100), 93.6% (95% CI, 78.35-100), and 93.6% (95% CI, 78.35-100), respectively. Survival rates at 30 days, 1 year, and 3 years were 97.6% (95% CI, 92.95-100), 86% (95% CI, 75.3-98.3), and 86% (95% CI, 75.3-98.3), respectively. Follow-up ranged from 1 month to 8.7 years (mean time, 21 months). Complications occurred in 22 patients (52%) and included wound complications (n = 19; 45.2%); deep vein thrombosis (n = 1; 2.4%); anastomotic breakdown (n = 1; 2.4%); hematoma (n = 4; 9.5%); pulmonary embolism (n = 2; 4.8%); and compartment syndrome (n = 2; 4.8%). Conclusions: The SFV is a durable conduit for uses beyond aortic reconstruction and should be considered when the great saphenous vein is not available or size match is a concern. However, wound complications remain a problem. © 2012 Society for Vascular Surgery.

Ten versus five polymorphonuclear leukocytes as threshold in frozen section tests for periprosthetic infection: a meta-analysis

PJI DX Updated Search

We objectively appraised available evidence regarding the threshold for the number of polymorphonuclear leukocytes required in frozen section tests used to diagnose periprosthetic infection. Pooled summary estimates for sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio (OR) were compared for ten and five polymorphonuclear leukocytes per high power field as the threshold. The total cohort included 1011 patients and the rate of infection was 19.2%. Although there was no difference in sensitivity or diagnostic OR, specificity was significantly higher for ten than for five polymorphonuclear leukocytes per high power field (p=0.007) In sum, a threshold of 10 polymorphonuclear leukocytes is better for diagnosing periprosthetic infections

Chemotherapy of rhabdomyosarcoma by regional perfusion: a case report

MSTS 2018 - Femur Mets and MM

A 14 month old girl was brought to the hospital with a 3 month history of swelling of the right calf. Incisional biopsy of the mass, which clinically involved all the calf muscles, revealed embryonal rhabdomyosarcoma. Clinically there was no regional lymph node involvement. The patient underwent isolated right lower extremity perfusion through the common femoral vessels. Drugs and dosages for this 9 kg patient were as follows: melphalan, 10 mg: Actinomycin D, 0.2 mg; nitrogen mustard, 2 mg. Biopsy of the femoral nodes at that time revealed no metastatic disease. Groin dissection was not performed. For approximately one week postoperatively, the patient had edema and redness of the extremity, which resolved with supportive therapy. There were no systemic side effects, such as bone marrow suppression. Within 3 weeks the tumor was barely palpable. The patient was started on adjunctive systemic chemotherapy consisting of Actinomycin D, vincristine and cyclophosphamide. She remained clinically free of disease on follow up examination 10 months following treatment.

Safety of rivaroxaban with neuraxial anaesthesia for total hip or knee replacement surgery

Surgical Management of Osteoarthritis of the Knee CPG

Aims: Pts receiving anticoagulants are at risk of developing spinal haematoma when neuraxial anaesthesia is used (epidural or spinal with/without an indwelling epidural catheter). Rivaroxaban - an oral, direct Factor Xa inhibitor - was compared with enoxaparin for the prevention of venous thromboembolism after total hip or knee replacement in the phase III RECORD programme. Ethics committee approval was granted.The incidences of spinal haematoma and haemorrhagic complications from the pooled RECORD data were used to evaluate the safety of rivaroxaban with neuraxial anaesthesia. Methods: Anaesthesia protocols were at the discretion of the treating physicians, and reported through Case Report Forms. Pts were not allocated to study drugs by type of anaesthesia. If epidural catheters were used, removal was timed according to the pharmacokinetic characteristics of the study drug. The RECORD programme was not designed to evaluate anaesthesiology-related issues, but intraspinal bleeding or haemorrhagic puncture events were recorded as part of the criteria for major bleeding - the primary safety endpoint of the RECORD studies. Results: Of 12,383 pts who received study medication, a total of 8,176 (66%) received neuraxial anaesthesia: 4,086 in the rivaroxaban group and 4,090 in the enoxaparin groups. Of these 1,141 (rivaroxaban) and 1,160 (enoxaparin), respectively, received epidural anaesthesia, of whom 913 (80%) and 897 (77%), respectively, had indwelling epidural catheters. The Table 1 shows spinal haematoma and haemorrhagic events related to neuraxial anaesthesia. Conclusions: No safety concerns were identified when rivaroxaban was used with neuraxial anaesthesia - with or without indwelling epidural catheters in a subset of 4,086 pts from the RECORD programme (Table presented)

Intentional and unintentional weight loss increase bone loss and hip fracture risk in older women

Management of Hip Fractures in the Elderly

OBJECTIVES: To test the hypothesis that unintentional weight loss increases the rate of bone loss and risk of hip fracture more than intentional weight loss. DESIGN: Prospective cohort study. SETTING: Four communities within the United States. PARTICIPANTS: Six thousand seven hundred eighty-five elderly white women with measurement of weight change and assessment of intention to lose weight. MEASUREMENTS: Weight change between baseline and fourth examinations (average 5.7 years between examinations) and assessment of intention to lose weight. Weight loss was defined as a decrease of 5% or more from baseline weight, stable weight was defined as less than a 5% change from baseline weight, and weight gain was defined as an increase of 5% or more from baseline weight. Rate of change in bone mineral density at the hip between fourth and sixth examinations (average 4.4 years between examinations) was measured using dual-energy x-ray absorptiometry. Incident hip fractures occurring after the fourth examination until June 1, 2001 (average follow-up 6.6 years) was confirmed using radiographic reports. RESULTS: The adjusted average rate of decline in total hipbone density steadily increased from -0.52% per year in women with weight gain to -0.68% per year in women with stable weight to -0.92% per year in women with weight loss (P-value for trend <.001). Higher rates of hip-bone loss were observed in women with weight loss irrespective of body mass index (BMI) or intention to lose weight. During follow-up of an average 6.6 years after the fourth examination, 400 (6%) of the cohort suffered a first hip fracture. Women with weight loss had 1.8 times the risk (95% confidence interval (CI)=1.43-2.24) of subsequent hip fracture as those with stable or increasing weight. The association between weight loss and increased risk of hip fracture was consistent across categories of BMI and intention to lose weight. Even voluntary weight loss in overweight women with a BMI of 25.9 kg/m2 (median) or greater increased the risk of hip fracture (multivariate hazard ratio=2.48, 95% CI=1.33-4.62). CONCLUSION: Older women who experience weight loss in later years have increased rates of hip-bone loss and a two-fold greater risk of subsequent hip fracture, irrespective of current weight or intention to lose weight. These findings indicate that even voluntary weight loss in overweight elderly women increases hip fracture risk

Smaller Radius Width in Women With Distal Radius Fractures Compared to Women Without Fractures

Distal Radius Fractures

Introduction Bone mineral density (BMD) measured using dual-energy x-ray absorptiometry (DXA) is typically used to assess fracture risk. However, other factors such as bone size and the forward momentum of a fall (a function of body size) can also potentially influence fracture risk, but are understudied. This report describes the characteristics of a cohort of Caucasian pre- and postmenopausal women with distal radius fractures (DRF) after falling onto an outstretched hand.

Preemptive oral rofecoxib plus postoperative intraarticular bupivacaine for pain relief after arthroscopic knee surgery

OAK 3 - Non-arthroplasty tx of OAK

This study was designed to test the hypothesis whether preemptive administration of rofecoxib, a novel selective COX�2 inhibitor, can prolong intraarticular bupivacaine analgesia after arthroscopic knee surgery. Sixty�two patients were randomly assigned to one of the three groups. Group 1 (n=21) was administered oral rofecoxib 50 mg 1 h before surgery plus intraarticular 0.5 % bupivacaine 20 ml postoperatively. Group 2 (n=21) was administered the same dose of bupivacaine. Group 3 (n=20) was administered saline 20 ml intraarticularly after surgery. Pain scores (VAS) were assessed at 30 min, 1, 2, 4, 6, 12 and 24 h postoperatively. Analgesia duration, analgesic (tramadol and tenoxicam) requirements, and adverse effects were recorded postoperatively for 24 h. Pain scores were significantly lower in the Group 1 at all time points (p<0.05, p<0.001) and were significantly lower in the Group 2 at 30 min (p<0.001), 1 and 4 h (p<0.05) compared to the Group 3. Pain scores were significantly lower in the Group 1 compared to the Group 2 during the first 4 h after surgery (p<0.05, p<0.001). Analgesia duration was longer in Group 1 than Group 2 or 3 (743.0 +/� 480.5 min versus 262.4 +/� 292.2 min and 17.0 +/� 12.1 min; p<0.05, p<0.001 respectively), and in Group 2 than Group 3 (p<0.05). Tramadol requirements were significantly less in Group 1 than Group 2 and 3 (4.8 +/� 15.0 mg versus 40.5 +/� 43.6 mg and 67.5 +/� 24.5 mg; p<0.05, p<0.001 respectively), and in Group 2 than Group 3 (p<0.05). There were no significant differences among the groups regarding the tenoxicam requirements and adverse effects. In conclusion, the combination of oral rofecoxib administered preemptively and intraarticular bupivacaine administered postoperatively provided a significant analgesic benefit and decreased the opioid requirements after arthroscopic knee surgery, when compared to bupivacaine alone or saline.

Upper extremity complications in hemodialysis patients: Recommendations and a review of the literature

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

This article presents a summary of upper extremity complications common in the hemodialysis patient population, including nerve entrapment syndromes, edema, and peripheral neuropathies. In order to preserve hand function in this susceptible population, the author emphasizes the importance of renal dialysis center staff being able to identify and to refer, in a timely manner; those patients exhibiting changes in their hand function due to dialysis-related complications. A simple checklist questionnaire which may be used as an upper extremity screening tool to identify changes in hand function is included, as well as recommended screening tests and warning signs of potential hand dysfunction

Psychological Resilience Is Associated With Participation Outcomes Following Mild to Severe Traumatic Brain Injury

DoD PRF (Psychosocial RF)

Traumatic brain injury (TBI) causes physical and cognitive-behavioral impairments that reduce participation in employment, leisure, and social relationships. Demographic and injury-related factors account for a small proportion of variance in participation post-injury. Personal factors such as resilience may also impact outcomes. This study aimed to examine the association of resilience alongside demographic, injury-related, cognitive, emotional, and family factors with participation following TBI. It was hypothesized that resilience would make an independent contribution to participation outcomes after TBI. Participants included 245 individuals with mild-severe TBI [M_age = 44.41, SD_age = 16.09; post traumatic amnesia (PTA) duration M 24.95 days, SD 45.99] who completed the Participation Assessment with Recombined Tools-Objective (PART-O), TBI Quality of Life Resilience scale, Family Assessment Device General Functioning Scale, Rey Auditory Verbal Learning Test, National Adult Reading Test, and Hospital Anxiety and Depression Scale an average 4.63 years post-injury (SD 3.02, R 0.5-13). Multiple regression analyses were used to examine predictors of PART-O scores as the participation measure. Variables in the model accounted for a significant 38% of the variability in participation outcomes, F_{(13, 211)} = 9.93, p < 0.05, R² = 0.38, adjusted R² = 0.34. Resilience was a significant predictor of higher participation, along with shorter PTA duration, more years since injury, higher education and IQ, and younger age. Mediation analyses revealed depression mediated the relationship between resilience and participation. As greater resilience may protect against depression and enhance participation this may be a focus of intervention.

Anatomic and Reverse Total Shoulder Arthroplasty in Patients Older Than 80 Years

Glenohumeral Joint OA

Anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) are routinely performed in patients older than 80 years. Often unaware of the differences between the 2 procedures, patients may expect similar outcomes from these procedures. This article reports the outcomes of primary TSA and RSA in patients older than 80 years, with attention directed toward differences in outcomes between the procedures. The authors evaluated a consecutive series of patients who were at least 80 years old and were treated with primary shoulder arthroplasty and had a minimum follow-up of 2 years. Of these patients, 18 underwent primary TSA for osteoarthritis and 33 underwent primary RSA for rotator cuff tear arthropathy. Pain scores, function scores, and range of motion were evaluated preoperatively and at final follow-up. Perioperative and postoperative complications, transfusion rates, length of stay, and subjective satisfaction with the outcome were reported. In these patients, TSA and RSA were similarly effective in improving pain scores, functional scores, and range of motion measurements. Patients who had TSA reported significantly greater satisfaction with surgery and had superior American Shoulder and Elbow Society total and function scores, forward elevation, and external rotation, but similar net improvement from preoperative levels. Although no significant differences were shown in complications, length of stay, or requirement for transfusion, patients treated with RSA had higher rates of transfusion and postoperative complications. Both procedures were similarly effective treatments for patients older than 80 years and showed similar improvements in pain, function, and motion. Patients undergoing RSA were less likely to have good to excellent results, with higher complication and transfusion rates.

Preoperative nutritional status of the surgical patients in Jeju

Hip Fx in the Elderly 2019

BACKGROUND: To assess the preoperative nutritional status of patients with various disorders and to provide data for pre- and postoperative patient management plans, particularly in the elderly. There is no published information on age-matched and disease-matched preoperative nutritional/immunologic status for orthopedic patients, especially in the elderly, in Jeju. METHODS: In total, 331 patients with four categories of orthopedic conditions were assessed: 92 elective surgery patients, 59 arthroplasty patients, 145 patients with fractures, and 35 infection patients. Malnutrition was defined as body mass index (BMI) below 18 kg/m(2) of expected body weight (below 20% of normal), serum albumin/globulin ratio below 1.5 (normal range, 1.5 to 2.3), albumin level below 3.5 g/dL, total lymphocyte count below 1,500 cells/mm(3), and lymphocyte/monocyte ratio below 5 versus 1. RESULTS: In 92 elective surgery patients, the average BMI was 23 kg/m(2), hemoglobin was 15 g/dL, lymphocytes (2,486 cells)/monocytes (465 cells) ratio was 6.1, and the albumin (4.4 g/dL)/globulin (2.5 g/dL) ratio as a protein quotient was 1.7. Among the 59 hip and knee arthroplasty patients, the average BMI was 25 kg/m(2), hemoglobin was 12 g/dL, lymphocytes (2,038 cells)/monocytes (391 cells) ratio was 6.6, and albumin (4.1 g/dL)/globulin (2.4 g/dL) ratio was 1.6. No subject showed malnutrition. Among the 145 fracture patients, the average BMI was 23 kg/m(2). The hemoglobin level was 13 g/dL, monocytes (495 cells)/lymphocytes (1,905 cells) ratio was 1 versus 4.6, and albumin (4.1 d/gL)/globulin (2.5 d/gL) ratio was 1.6. However, both ratios decreased after 70 years of age. Among the 17 of 35 infection patients, albumin levels were below 3.5 g/dL, the average BMI was 22 kg/m(2), lymphocytes (1,532 cells)/monocytes (545 cells) ratio was 2.4 versus 1, and albumin (3.0 g/dL)/globulin (3.3 g/dL) ratio was 0.9, while in 18 patients albumin levels were over 3.5 g/dL, the average BMI was 22 kg/m(2), hemoglobin was 12 g/dL, lymphocytes (1,998 cells)/monocytes (583 cells) ratio was 3 versus 1, and albumin/globulin ratio was 1.4. Thus, in the infection group, approximately 50% of the patients showed poor nutrition and immunosuppression. CONCLUSIONS: It was found that nutritional and immune condition deteriorated gradually to some degree in elderly patients over 60 years of age.

Terminal branch of anterior interosseous nerve as source of wrist pain

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

The terminal branch of the anterior interosseous nerve is described anatomically and demonstrated histologically. Injury to this nerve can be the source of persistent, dull aching volar wrist pain. Suitability for partial volar wrist denervation is determined by functional testing before and after a diagnostic nerve block. Experience with twelve patients with this problem is presented

The influence of diabetes mellitus on the post-operative outcome of elective primary total knee replacement: A systematic review and meta-analysis

DoD SSI (Surgical Site Infections)

Total knee replacement (TKR) is an effective method of treating end-stage arthritis of the knee. It is not, however, a procedure without risk due to a number of factors, one of which is diabetes mellitus. The purpose of this study was to estimate the general prevalence of diabetes in patients about to undergo primary TKR and to determine whether diabetes mellitus adversely affects the outcome. We conducted a systematic review and metaanalysis according to the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The Odds Ratio (OR) and mean difference (MD) were used to represent the estimate of risk of a specific outcome. Our results showed the prevalence of diabetes mellitus among patients undergoing TKR was 12.2%. Patients with diabetes mellitus had an increased risk of deep infection (OR = 1.61, 95% confidence interval (CI), 1.38 to 1.88), deep vein thrombosis (in Asia, OR = 2.57, 95% CI, 1.58 to 4.20), periprosthetic fracture (OR = 1.89, 95% CI, 1.04 to 3.45), aseptic loosening (OR = 9.36, 95% CI, 4.63 to 18.90), and a poorer Knee Society function subscore (MD = -5.86, 95% CI, -10.27 to -1.46). Surgeons should advise patients specifically about these increased risks when obtaining informed consent and be meticulous about their peri-operative care.

Flexible intramedullary nails for unstable fractures of the tibia in children

DoD SSI (Surgical Site Infections)

Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children. We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails. Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome. We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children. © 2006 British Editorial Society of Bone and Joint Surgery.

Fat preserving by laser 1210-nm

Panniculectomy & Abdominoplasty CPG

INTRODUCTION: The 1210-nm wavelength has absorption-affinity for Lipid-Rich Tissue and has demonstrated to stimulate adipocytes and mesenchymal cells of the subcutaneous tissue, with a new concept: Selective Photothermostimulation (SPS). The application in Liposuction of this wavelength is determined by its preservation of the integrity of adipocytes, making possible the use of these materials for fat grafting in Liposculpture, Breast Reconstruction or as filler in Face Rejuvenation, proven that this technique is less traumatic. MATERIALS AND METHODS: 102 patients diagnosed with lipodystrophy either associated to skin flaccidity or not were applied the 1210-nm diode laser (ORlight(R)) between June 2010 and August 2011. The protocol was followed and verified through ultrasound imaging. Intraoperative and subcutaneous cellular tissue temperatures were measured. Samples of the aspirated tissue were sent for histological analysis to prove alteration/preservation of adipocytes and connective tissues, including mitochondrial activity. RESULTS: Histological analyses revealed 98% preservation of aspirated adipocytes. The 1210-nm diode laser shows affinity for adipose tissue. In addition, the technique poses a reduced trauma level on tissues, allowing for the performance of associated procedures for the body or face. No major complications were observed; and only minor complications, mainly ecchymosis on 2% of the total body surface area, have been recorded. The recovery period is 24 hours. The Liposuction Diode Laser (LSDL) 1210-nm is ideal for Liposculpture.

Coronal fat suppression fast spin echo images of the knee: evaluation of 202 patients with arthroscopic correlation

AMP (Acute Meniscal Pathology)

We optimized fat-suppressed fast spin echo (FS-FSE) parameters for coronal imaging of the knee and then evaluated the technique in a clinical setting. Five volunteers and 12 patients were used to evaluate various repetition (TR), echo (TE), and echo train lengths (ETL). Then, 202 patients underwent both knee MR imaging using coronal plane FS-FSE and arthroscopy. The coronal FS-FSE images were compared with radial multiplanar gradient-recalled echo (MPGRE), axial T1-weighted SE, and parasagittal double echo SE images. Proton density images (2,000/19) with an ETL of 2 best depicted the menisci, ligaments, and capsules. The conspicuity of osteochondral abnormalities depicted by the coronal FS-FSE imaging was significantly higher than for axial T1-weighted SE (p < .003) and parasagittal echo SE images (p < .003). The accuracy of the coronal FS-FSE imaging for medial and lateral meniscal tears was 91.6% and 87.6%, respectively. Combined imaging interpretation of the coronal FS-FSE, axial T1-weighted SE, and radial MPGRE imaging improved the accuracy for meniscal tears slightly over any sequence used alone, but the difference was not statistically significant. Fourteen capsular injuries were demonstrated by the coronal FS-FSE imaging. FS-FSE imaging in the coronal plane is a useful complementary sequence in MR examinations of the knee for the evaluation of meniscal tears, capsular injuries, and osteochondral abnormalities.

Time to Block: Early Regional Anesthesia Improves Pain Control in Geriatric Hip Fractures

Hip Fx in the Elderly 2019

BACKGROUND: Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events. METHODS: This prospective cohort study included patients who were â?¥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB. RESULTS: There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay. CONCLUSIONS: Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anatomy of a defective barrier: Sequential glove leak detection in a surgical and dental environment

Dental Implant Infection

Objectives: a) To determine the frequency of perforations in latex surgical gloves before, during, and after surgical and dental procedures; b) to evaluate the topographical distribution of perforations in latex surgical gloves after surgical and dental procedures; and c) to validate methods of testing for latex surgical glove patency. Design: Multitrial tests under in vitro conditions and a prospective sequential patient study using consecutive testing. Setting: An outpatient dental clinic at a university dental school, the operating suite in a medical school affiliated with the Veteran's Hospital, and a biomechanics laboratory. Personnel: Surgeons, scrub nurses, and dental technicians participating in 50 surgical and 50 dental procedures. Methods: We collected 679 latex surgical gloves after surgical procedures and tested them for patency by using a water pressure test. We also employed an electronic glove leak detector before donning, after sequential time intervals, and upon termination of 47 surgical (sequential surgical), 50 dental (sequential dental), and in three orthopedic cases where double gloving was used. The electronic glove leak detector was validated by using electronic point-by-point surface probing, fluorescein dye diffusion, as well as detecting glove punctures made with a 27-gauge needle. Results: The random study indicated a leak rate of 33.0% (224 out of 679) in latex surgical gloves; the sequential surgical study demonstrated patency in 203 out of 347 gloves (58.5%); the sequential dental study showed 34 leaks in the 106 gloves used (32.1%); and with double gloving, the leak rate decreased to 25.0% (13 of 52 gloves tested). While the allowable FDA defect rate for unused latex surgical gloves is 1.5%, we noted defect rates in unused gloves of 5.5% in the sequential surgical, 1.9% in the sequential dental, and 4.0% in our electronic glove leak detector validating study. In the sequential surgical study, 52% of the leaks had occurred by 75 mins, and in the sequential dental study, 75% of the leaks developed by 30 mins. In terms of the anatomical localization, the thumb and forefinger accounted for more than 60% of the defects. There were no differences in the frequency of glove leaks between the left and right hand. Leak rates were highest for the surgeon (52%), followed by the first assistant (29%) and the scrub nurse (25%). No false negatives were noted using the electronic glove leak detector; one false positive was seen out of 225 gloves tested (0.44%), as noted in our validation studies. Conclusions: Significantly high glove leak rates were noted after surgical and dental procedures, indicating that the present day latex surgical gloves can become an incompetent barrier once they are used. Unused latex surgical gloves demonstrated a higher rate of defects than allowed by the Food and Drug Administration standards, indicating substantial noncompliance of quality control standards by manufacturers as well as inadequate governmental oversight. Double gloving, or the use of thicker latex surgical gloves, would probably reduce the frequency of glove leaks. Latex surgical gloves should be tested for patency before use and during surgical and dental procedures.

Comparison of the efficacy of a forced-air warming system and circulating-water mattress on core temperature and post-anesthesia shivering in elderly patients undergoing total knee arthroplasty under spinal anesthesia

AAHKS (8) Anesthetic Infiltration

Background: In the present study, we compared changes in body temperature and the occurrence of shivering in elderly patients undergoing total knee arthroplasty under spinal anesthesia during warming with either a forced-air warming system or a circulating-water mattress. Methods: Forty-six patients were randomly assigned to either the forced-air warming system (N = 23) or circulating-water mattress (N = 23) group. Core temperature was recorded using measurements at the tympanic membrane and rectum. In addition, the incidence and intensity of post-anesthesia shivering and verbal analogue score for thermal comfort were simultaneously assessed. Results: Core temperature outcomes did not differ between the groups. The incidence (13.0 vs 43.5%, P < 0.05) and intensity (20/2/1/0/0 vs 13/5/3/2/0, P < 0.05) of post-anesthesia shivering was significantly lower in the forced-air system group than in the circulating-water mattress group. Conclusions: The circulating-water mattress was as effective as the forced-air warming system for maintaining body temperature. However, the forced-air warming system was superior to the circulating-water mattress in reducing the incidence of post-anesthesia shivering. © the Korean Society of Anesthesiologists, 2014.

External fixation of distal femoral fractures in adults' multicentre retrospective study of 43 patients

DoD LSA (Limb Salvage vs Amputation)

BACKGROUND: A multicenter cohort of 43 adults with distal femoral fractures (DFFs) managed with external fixation was evaluated to determine the potential of this treatment. PATIENTS AND METHODS: The patients were young adults (mean age: 39.6 years) with high-energy trauma; 12 had polytrauma and 41 multiple fractures. Most patients (38/43) had compound DFFs. Fracture types were A in 3 patients, B in 3 patients, and C in 37 patients. A tibio-femoral construct was required in 11 patients and a femoro-femoral construct in 32 patients. RESULTS: The normal femoral axis was restored within 5 degrees in the coronal plane in 34 (79%) patients and in the sagittal plane in 22 (51%) patients. Axis restoration within 5 degrees in both planes was achieved in 19 (44.7%) patients. After femoro-femoral external fixation, mean malalignment was 4.2 degrees in the coronal plane and 8.6 degrees in the sagittal plane; corresponding values after tibio-femoral external fixation were 1.3 degrees and 8.6 degrees . In 23 patients (of whom 1 was lost to follow-up), external fixation was intended as the only and definitive treatment; among them, 1 required amputation after a failed revascularization procedure, 10 achieved fracture healing within a mean of 21.2 weeks, 6 required conversion to another technique, and 5 underwent non-conservative procedures (total knee arthroplasty in 3 and arthrodesis in 2). In the remaining 20 patients, conversion to internal fixation was intended initially and performed within a mean of 4.7 weeks; 1 of these patients required amputation for ischemia, 3 did not achieve fracture healing, 12 achieved primary fracture healing, and 4 achieved fracture healing after repeated grafting (n=3) or osteotomy (n=1). At last follow-up (at least 1 year), the mean International Knee Society (IKS) Function Score was 67.3 and an IKS Knee Score of 68.5. Range of active flexion was 85.75 degrees overall, 62.3 degrees in the group with intended definitive external fixation and 101 degrees in the group with intended conversion to internal fixation. Healing without complications was achieved in 10 (43%) in the former group and 12 (60%) in the latter group. CONCLUSION: Our data support provisional external fixation followed by early conversion to internal fixation in patients with extensively compounded DFFs; patients with multiple fractures requiring several surgical procedures; and polytrauma patients awaiting hemodynamic, respiratory, or neurological stabilization. LEVEL OF EVIDENCE: IV, retrospective study.

Functional and radiographic outcome after tumor limb salvage surgery using STANMORE megaprostheses

PJI DX Updated Search

PURPOSE: To report the clinical and radiological outcome of limb salvage surgery with the STANMORE megaprostheses. METHODS: We retrospectively studied 33 patients with musculoskeletal tumor limb salvage surgery using STANMORE megaprostheses. Clinical evaluation was done using the Enneking and the Toronto Extremity Salvage Score (TESS). Radiographic evaluation was done using the International Society of Limb Salvage (ISOLS) score. RESULTS: At a mean follow-up of 18 months, 21 patients were alive with no evidence of disease and two patients were alive with metastatic disease; 9 patients died of metastatic disease and one patient of causes unrelated to the primary tumor. Local recurrence was not observed in any of the patients. The mean Enneking and TESS scores were 76 and 88.4%, respectively. The ISOLS score was excellent or good in 30 cases for bone remodelling, 30 cases for the interface, in 30 cases for anchorage, in 32 cases for the implant body, and in 33 cases for the articulation. Extracortical bone bridging greater than 25% was observed in 8 prostheses. Mechanical survival of the megaprostheses was 97% (32 megaprostheses). Complications included seroma and hematoma formation (12%), skin necrosis and dehiscence at the knee wound (9%), aseptic loosening and infection (6%), quadriceps tendon rupture and peroneal nerve palsy (3%). CONCLUSION: The local recurrence-free survival in this series supports limb salvage surgery. The 97% survival rate of the megaprostheses suggests that the STANMORE modular megaprostheses are valuable for reconstruction of bone defects after tumor resection

Clinical features of nonpituitary sellar lesions in a large surgical series

Upper Eyelid and Brow Surgery

CONTEXT: Pituitary adenomas are the most common lesions in the sellar region, but other pathologies need to be considered in the differential diagnosis. OBJECTIVE: To assess the prevalence of unusual sellar masses in a large series of patients and identify clinicopathological factors that may aid the pre-operative diagnosis. DESIGN: Retrospective case series. PATIENTS: We analysed the records of 1469 transsphenoidal procedures performed between 1998 and 2009. One hundred sixteen cases (7.9%) were not pituitary adenomas. MEASUREMENTS: Final pathological diagnosis. RESULTS: One hundred sixteen patients (45 men, 71 women; mean age (+/-SD): 45 +/- 17 years) with nonadenomatous lesions were divided into four major aetiological groups: cystic lesions (CYS) (53%); benign neoplasms (BEN) (22%); malignancies (MAL) (16%) and inflammatory lesions (INF) (9%). Rathke's cysts, the most common lesions, represented 42% of all cases. Twenty-five per cent of malignant lesions were metastases, and some of the MAL (e.g., fibrosarcoma, lung metastasis) had a radiographical appearance suggestive of a pituitary adenoma. The most common presenting symptoms were visual field impairment (51%) and headache (34%). Pre-operative pituitary dysfunction was present in 58% of cases, with hyperprolactinaemia (35%), hypogonadism (23%) and hypocortisolism (23%) found most frequently. Postoperative resolution of headache and visual symptoms occurred in 63% and 65% of patients, respectively. Hyperprolactinaemia resolved in 77% of cases. CONCLUSIONS: A substantial minority of sellar masses are not pituitary adenomas. While they frequently present with the symptoms, hormone abnormalities and radiographical appearance typical of pituitary tumours, the possibility of a nonadenomatous lesion needs to be considered in the differential diagnosis.

The role of radiotherapy in patients undergoing mastectomy for carcinoma of the breast

MSTS 2018 - Femur Mets and MM

Several factors, including T stage, nodal involvement, grade, the presence of lymphovascular invasion, and possibly involved or close surgical margins, have been found to affect local recurrence after mastectomy. The majority of recurrences will occur in the first 5 years and 50% of patients will have metastatic disease at the time of recurrence. Early studies on the use of adjuvant radiotherapy are difficult to interpret owing to poor radiotherapy techniques, inadequate dose or a variety of confounding variables within a particular trial. More recent reports have confirmed that adjuvant radiotherapy will reduce the risk of local recurrence and in tumours of <5 cm with involved nodes, produce a reduction in breast cancer deaths. Improvements in breast cancer mortality may however be counterbalanced by increases in cardiac events and deaths caused by second malignancies. This stresses the importance of using megavoltage irradiation and avoiding excess cardiac doses particularly when treating left-sided tumours. Adjuvant radiotherapy combined with tamoxifen has been shown to produce an improvement in both local control and survival in postmenopausal node-positive patients who have undergone mastectomy. Adjuvant radiation combined with systemic chemotherapy has a significant effect on local recurrence and probably on survival in node-positive patients after mastectomy. There is little controversy over its role in patients with tumours >5 cm, with more than four nodes involved or with one to three nodes with extracapsular extension, or in those in whom axillary surgery has been deemed inadequate (i.e. <10 nodes). Debate still exists concerning T1/T2, G1/G2 tumours with only one to three nodes involved when the axillary surgery has been satisfactory (>10 nodes). The ongoing Intergroup trial may answer this question but until then other factors such as tumour grade and the presence of lymphovascular invasion can be included in the equation to determine which of the patients in the latter group should receive postoperative radiotherapy. Controversy still exists about what fields should be irradiated and in particular whether the supraclavicular fossa and internal mammary node chain should be included in adjuvant therapy. The EORTC is presently conducting a randomized trial, which should give us the answer. Treatment at relapse on the chest wall may require a combination of surgery, radiotherapy and chemotherapy, depending on previous therapy. If radiotherapy has not previously been used, then wide-field irradiation should be administered, including both chest wall and supraclavicular fossa with or without the axilla, depending on the extent of previous axillary surgery and the risk of lymphoedema. Re-irradiation after radical adjuvant radiotherapy can be considered only for selected patients when an adequate discussion with them has taken place with regard to the relative benefits versus toxicity. [References: 55]

The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review

Surgical Management of Osteoarthritis of the Knee CPG

BACKGROUND: The increase in the number of individuals with an unhealthy high body weight is particularly relevant in the United States. Obesity (body mass index >/= 30 kg/m2) is a well-documented risk factor for the development of osteoarthritis. Furthermore, an increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades. The primary aim of this systematic literature review was to determine whether obesity has a negative influence on outcome after primary total knee arthroplasty. METHODS: A search of the literature was performed, and studies comparing the outcome of total knee arthroplasty in different weight groups were included. The methodology of the included studies was scored according to the Cochrane guidelines. Data extraction and pooling were performed. The weighted mean difference for continuous data and the weighted odds ratio for dichotomous variables were calculated. Heterogeneity was calculated with use of the I2 statistic. RESULTS: After consensus was reached, twenty studies were included in the data analysis. The presence of any infection was reported in fourteen studies including 15,276 patients (I2, 26%). Overall, infection occurred more often in obese patients, with an odds ratio of 1.90 (95% confidence interval [CI], 1.46 to 2.47). Deep infection requiring surgical debridement was reported in nine studies including 5061 patients (I2, 0%). Deep infection occurred more often in obese patients, with an odds ratio of 2.38 (95% CI, 1.28 to 4.55). Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason, was documented in eleven studies including 12,101 patients (I2, 25%). Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30 (95% CI, 1.02 to 1.67). CONCLUSIONS: Obesity had a negative influence on outcome after total knee arthroplasty

Common pain generators after total shoulder arthroplasty and their pesky relatives

Trial Systematic Review Project

Although anatomic and reverse total shoulder arthroplasty (TSA) are generally very successful procedures with predictable pain relief, a small percentage of patients experience refractory pain postoperatively. Common etiologies of pain following such surgery are infection and joint instability in the early postoperative period, as well as implant loosening beyond 2 years postoperatively. However, once these causes of pain are ruled out, less common etiologies should be considered. These less common causes of postoperative pain include psychological factors (i.e., depression and anxiety), physiologic (i.e., narcotic dependence and neurologic), mechanical (i.e., symptomatic hardware and acromioclavicular arthritis), or secondary gain (i.e., workman's compensation and insurance issues).

Minimally invasive techniques for pain palliation in extraspinal bone metastases: A review of cementoplasty and radiofrequency ablation

MSTS 2018 - Femur Mets and MM

Minimally invasive techniques are an effective primary or alternative modality for pain palliation in extraspinal bone metastases, particularly when conventional therapies such as localized radiation therapy leave a subset of patients with refractory pain. Cementoplasty is hypothesized to work through the stabilization of microfractures and has been most commonly performed in osteolytic lesions of the femur and acetabulum. Specific indications and contraindications are highlighted for both locations. Radiofrequency ablation is hypothesized to reduce pain through tumor reduction and periosteal nerve destruction and has been studied most extensively in the pelvis and chest wall. Radiofrequency ablation combined with localized radiation therapy has shown promising improvement in pain relief compared to radiation therapy alone, and combination cementoplasty and radiofrequency ablation may have specific benefit in the acetabulum. Both cementoplasty and radiofrequency ablation have been shown to work as soon as within 24 hours and for as long as 6 months. Future prospective, randomized trials are needed to compare the efficacy of these treatments.

Prospective comparison of surgery alone and chemoradiotherapy with selective surgery in resectable squamous cell carcinoma of the esophagus

Reconstruction After Skin Cancer

PURPOSE: Esophagectomy remains the mainstay treatment for esophageal cancer, although retrospective studies have suggested that chemoradiotherapy (CRT) is as effective as surgery. To determine whether CRT can substitute for surgery as the primary treatment modality, we performed a prospective direct comparison of outcomes after treatment in patients with resectable esophageal cancer who had received CRT and those who had undergone surgery. METHODS AND MATERIALS: Eligible patients had resectable T1-3N0-1M0 thoracic esophageal cancer. After the surgeon explained the treatments in detail, the patients selected either CRT (CRT group) or surgery (OP group). The CRT course consisted of two cycles of cisplatin and fluorouracil with split-course concurrent radiotherapy of 60Gy in 30 fractions. Patients with progressive disease during CRT and/or with persistent or recurrent disease after CRT underwent salvage resection. RESULTS: Of 99 eligible patients with squamous cell carcinoma registered between January 2001 and December 2005, 51 selected CRT and 48 selected surgery. Of the patients in the CRT group, 13 (25.5%) underwent esophagectomy as salvage therapy. The 3- and 5-year survival rates were 78.3% and 75.7%, respectively, in the CRT group compared with 56.9% and 50.9%, respectively, in the OP group (p = 0.0169). Patients in the OP group had significantly more metastatic recurrence than those in the CRT group. CONCLUSIONS: Treatment outcomes among patients with resectable thoracic esophageal squamous cell carcinoma were comparable or superior after CRT (with salvage therapy if needed) to outcomes after surgery alone

Transfusion drains versus suction drains in total knee replacement: meta-analysis

PJI DX Updated Search

PURPOSE: The use of autologous blood transfusion drains in orthopaedic surgery has been the subject of debate for several years. The aim of this meta-analysis was to review the use of autologous blood transfusion drains in total knee replacement. METHODS: The primary outcomes were as follows: the number of patients requiring homologous blood transfusion, pre-operative haemoglobin and post-operative haemoglobin days 5-7. The secondary outcome measures for the meta-analysis were drainage volume, length of hospital stay, average number of units transfused per patient, post-operative wound infection, and deep vein thrombosis. RESULTS: Eight randomised controlled trials met the inclusion criteria and were included in this analysis. Autologous transfusion drains were associated with a decrease in the number of patients requiring post-operative blood transfusion (pooled odds ratio = 0.36, 95% CI = 0.15-0.85, P = 0.02), the number of units transfused per patient (weighted mean difference = -0.84 (95% CI = -1.13 to -0.56), P < 0.0001), and length of hospital stay (weighted mean difference = -0.25 (95% CI = -0.48 to -0.01), P = 0.04). CONCLUSION: The results of our study highlight both likely clinical and economic benefits within total knee replacement surgery. The clinical benefits of autologous transfusion drains in the total knee replacement surgery suggested by this meta-analysis include a reduced requirement for post-operative blood transfusion and a shorter length of hospital stay. However, further large-scale high-powered randomized controlled trials are recommended to further elucidate subtle effects of autologous drains on post-operative outcome following total knee replacement. LEVEL OF EVIDENCE: II

Use of a Modular Tapered Fluted Femoral Component in Revision Total Hip Arthroplasty Following Resection of a Previously Infected Total Hip: Minimum 5-year Follow-Up

AAHKS (2) Corticosteroids

Femoral reconstruction in the setting of two stage reimplantation can be difficult and substantial reoperation rates due to implant loosening have been reported. We retrospectively reviewed 28 male and 29 female patients who underwent a two-stage reimplantation using a modular, tapered femoral stem. The mean clinical follow-up was 62. months. The mean Harris Hip score at 5-year follow-up was 76. Two stems were revised for aseptic loosening. Reinfection occurred in 16% of patients. Stem survivorship was 87% at 5-years. Use of a modular tapered stem provided a high rate of stable femoral fixation and acceptable rate of reinfection in two stage treatment of infected THA.

FNAC - Giant cell tumor of bone a study of 13 cases (Part III)

MSTS 2022 - Metastatic Disease of the Humerus

Analysis of FNAC of bone tumors over over a period of 11 1/2 years (Jan 1991 - June 2002) revealed 13 cases of Giant cell tumors. Histopathology was available for comparison in all the cases. On FNAC 12 cases were diagnosed as Giant cell tumors and one case as Aneurysmal bone cyst. The histopathology showed 11 cases of conventional giant cell tumors, one case of Giant cell tumor with secondary Aneurysmal bone cyst and one case as primary malignant Giant cell tumor (G C T and fibrosarcoma). Thus the overall sensitivity was 92.4% and Specificity of 88.4%. 11 cases were originating from long bone with typical epiphyseal location in 10 cases and metaphyseal in one case. Remaining 2 cases originated from metacarpals.FNAC smears in the context of clinical data and radiographic finding were characteristic of Giant cell tumor, comprising of closely intermixed, 2 cell population of mononuclear spindle and giant cells of osteoclast type. Other giant cell lesions, tumor and tumor like which need exclusion before making diagnosed of Giant cell tumor, have been discussed. The study proves that the pre- operative value of FNAC diagnosed of GiantI cell tumor bone in the context of clinical data and radiographs can avoid more invasive procedure of open or needle core biopsy.

Assessment of the ratio of carpal contents to carpal tunnel volume in patients with carpal tunnel syndrome: a preliminary report

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

An anatomic basis for carpal tunnel syndrome (CTS) has been proposed but not confirmed; both volumetric and area studies have been used to address this issue. The authors have demonstrated that the ratio of the carpal tunnel contents (CTC) to carpal tunnel volume (CTV) provides information regarding the relative free space in the carpal tunnel as compared with canal volume alone. This study was undertaken to determine whether the CTC/CTV ratio was higher for patients with CTS than for normal subjects. Seven asymptomatic volunteers and 7 patients with symptoms of CTS underwent magnetic resonance imaging (MRI) so that the CTC/CTV ratios could be determined. Standard radiographs were analyzed to identify plain radiographic variables that differed between patients with CTS and control subjects, and no differences were found. On MRIs, however, CTC/CTV ratios were noted to be higher for patients with CTS than for matched control subjects

Compression of the ulnar nerve at the wrist by anatomical variation anterior ulnar muscle about one case

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

Introduction.- The compression of the ulnar nerve is the second compressive neuropathy after carpal tunnel syndrome. The most common site of compression is elbow, but compressions are described all along its path in particular at the Guyon's canal. The etiology of idiopathic compressions is usually at the elbow as opposed to Guyon's canal where we find frequently extrinsic or intrinsic compression agent. We report a rare case of ulnar nerve compression at the wrist by an anatomical variation of the flexor carpi ulnaris. Observation.- It is a 40 years old woman, right-handed, who consulted for tingling and paraesthesia at the territory of the ulnar nerve. At the clinical examination the patient has a decreased sensitivity and motricity of the ulnar nerve with the presence of an elongated mass of ulnar border of the wrist the ultrasound showed muscle hypertrophy that was confirmed by MRI, EMG also confirmed a lengthening of sensory conduction of the ulnar nerve at this region. Discussion/Conclusion.- Surgical exploration revealed hypertrophy of flexor carpi goes down to Guyon's canal. The intervention consisted of a resection of a portion of muscle that compresses the ulnar nerve with neurolysis and opening of Guyon's canal, with good clinical improvement postoperatively. The ulnar nerve is rarely compressed at the wrist. This compression is most often and, unlike carpal tunnel, due to a local cause. Various published series are unfortunately too often oriented or too short effective to provide a statistically significant distribution of different etiologies enable encountered. The case report illustrates the diagnostic traps related to variations and muscle abnormalities. The contribution of MRI is useful for the diagnosis of anomalies and variations muscle

Do Regional Analgesia and Peripheral Blocks Still Have a Place in Joint Arthroplasty?

AAHKS (9/10) Regional Nerve Blocks

The efficacy of regional anesthesia and peripheral nerve blocks in the management of postoperative pain has resulted in widespread use of this approach in hip and knee arthroplasty. With extensive clinical use, however, the limitations of this approach have become apparent. These limitations include delays for the surgeon, inefficient use of the operating room, muscular weakness, and associated delays in physical therapy. Periarticular injection of anesthetic and analgesic medications appears to offer comparable benefits to nerve blocks in joint arthroplasty without these limitations. The long-acting anesthetic bupivacaine liposome injectable suspension (EXPAREL, Pacira Pharmaceuticals, Inc), in particular, has been shown to be highly effective in managing postoperative pain and reducing opioid consumption. Consequently, a growing body of data and extensive clinical experience now support replacing nerve blocks with periarticular injections.

The evaluation of tiodonium chloride as an antiplaque and anticaries agent. V. Effects on plaque microbiology and plaque and saliva pH

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The purpose of this study was to determine the effect of a tiodonium chloride mouthrinse on the microbial composition of plaque and the acidogenic properties of plaque and saliva after challenge with sucrose solutions. Fifty-five participants were grouped on the basis of their tendency to form plaque, then randomly assigned to use either a placebo or a 0.3% tiodonium chloride rinse. After a prophylaxis all oral hygiene was suspended, supervised rinsings were conducted twice daily for four days and once on day 5. One-half hour after the last rinse, plaque was removed from the right mandibular second molar for microbiological evaluation. Plaque was also removed from the right quadrants and mixed with 10% sucrose. The pH of the mixture was measured immediately and after 15 minutes. Saliva was collected before and 30 minutes after the final rinse and mixed with 5% glucose. pH was determined initially and after five hours. Tiodonium chloride rinses significantly reduced the viable organisms in plaque. It also restricted the ability of plaque or saliva to metabolize sucrose as monitored by pH changes. The results suggest that tiodonium chloride might decrease dental caries because of its inhibiting effect on plaque microflora and acid production by plaque and saliva

Impaired weight transfer persists at least four months after hip fracture and rehabilitation

Hip Fx in the Elderly 2019

OBJECTIVE: To determine whether choice stepping reaction time performance is impaired in people after hip fracture and whether different aspects of choice stepping performance improve with rehabilitation. DESIGN: This study includes a secondary analysis of data obtained from participants in a randomized controlled trial of exercise after hip fracture. SETTING: Data were either collected in a hospital rehabilitation unit, research institute or participant homes. SUBJECTS: The hip fracture group (n = 91) were recruited from three rehabilitation hospitals in metropolitan Sydney. The control group (n = 77) were healthy age-, gender- and dwelling-matched controls, participating in unrelated studies of fall risk factors. MAIN MEASURES: Response time, movement time and total time components of the choice stepping reaction time test. RESULTS: Improvements in choice stepping reaction time were seen in people after hip fracture, during a 16-week rehabilitation period, however performance remained impaired (1808 +/- 663 ms), compared with matched controls (1029 +/- 255 ms, P<0.001). Further, choice stepping performance was significantly slower when transferring weight onto the affected leg (1271 +/- 615 ms), compared with the unaffected leg (1119 +/- 499 ms, P<0.001). CONCLUSIONS: Movement deficits are evident for an extended time frame following rehabilitation for hip fracture. The slower response time following the rehabilitation period highlights ongoing difficulties with weight transfer onto the affected leg.

What can we learn from a patient on dialysis for 42 years?

Diagnosis and Treatment of Carpal Tunnel Syndrome CPG

We performed autopsy on a 60-year-old Japanese man who had received dialysis for 42 years. He started on intermittent peritoneal dialysis in 1968, which was combined with hemodialysis in 1969. His serum calcium-phosphate balance and his blood pressure had been controlled well. Carpal tunnel syndrome occurred in 1984. Then lumbar spinal canal stenosis (SCS) occurred in 1997, followed by cervical SCS in 2000, destructive lumbar spondyloarthropathy (DSA) in 2002, and pathological fracture of the right femoral neck due to an enlarging bone cyst in 2006. All of his surgical specimens showed dialysis-related deposition of beta2MG amyloid (dialysis-related amyloidosis: DRA). Thereafter, lumbar and cervical spinal palsy progressed. In 2009, he developed severe paralytic ileus with dilatation of the sigmoid colon, and subsequently died of peritonitis due to necrotizing cholecystitis. Autopsy showed massive DRA deposits in his intestinal blood vessels and thickened spinal dura, resulting in the above-mentioned intestinal and spinal complications. However, his arterial tree, including the aorta and coronary arteries, showed very little atheroma. Strict control of the Ca-P balance and blood pressure may have prevented cardiovascular disease, while progress in dialysis technology delayed fatal complications of DRA and allowed this patient to survive on dialysis for 42 years

The morbidity associated with lost or irretrievable resected meniscal fragments

AMP (Acute Meniscal Pathology)

Between January 1984 and April 1989 pieces of already-separated meniscus were lost in the knees of 23 patients as a complication of knee arthroscopy. These patients were asked to complete a questionnaire with regard to their postoperative problems. Despite the fact that some of these pieces were up to 4 cm in length, only 3 patients were dissatisfied with the results and had to undergo arthroscopy once again. When compared with the total number of arthroscopies (2,927) performed in the same period, we found no significant differences in patient ages, accompanying injury patterns, nor the time they were unable to work. These surprisingly excellent results demonstrate that a lost piece of meniscus in the knee space does not always indicate immediate repeat arthroscopy. In most cases, this loose piece probably will adhere to a place inside the knee where it will no longer be a mechanical hindrance.

Are patients with hip fractures more osteoporotic? Review of the evidence

Management of Hip Fractures in the Elderly

This report critically reviews 15 case-control studies that disagree about whether patients who fracture their hip are significantly more osteoporotic than persons of similar age who do not. The most rigorously designed studies observed less bone mass in the hips of patients with fractures than in the hips of control subjects, but the differences were usually small and overlapping. Measurements at other sites in the skeleton did not consistently find differences. Those studies that protected against ascertainment bias generally found smaller differences than studies that did not. Patients with hip fractures do not appear to be distinctly more osteoporotic than persons of similar age. Therefore, factors besides bone mass, such as a tendency to fall, may be important determinants of which elderly persons will have fractures; thus, measurements of bone mass might not be a reliable way to identify those at greatest risk of hip fracture

Abdominal-based adipocutaneous advancement flap for reconstructing inguinal defects with contraindications to standard reconstructive approaches: a simple and safe salvage reconstructive option

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Groin wounds occurring after vascular surgical site infection, oncologic resection, or occasionally orthopedic surgery and trauma may represent a surgical challenge. Reconstruction of these defects by the usual workhorse flaps may be contraindicated following previous surgery and in patients with lower limb lymphedema or extreme morbidity. METHODS: This study included 15 consecutive patients presenting with inguinal wounds after vascular or general surgery that required debridement and soft tissue coverage. All cases had absolute or relative contraindications to conventional reconstructive techniques, including a compromised deep femoral artery network, limb lymphedema, scarring of potential flap harvesting sites, or poor overall condition. Abdominal adipocutaneous excess enabled the performance of adipocutaneous advancement flaps in an abdominoplasty-like fashion. Immediate and long-term outcomes were analyzed. RESULTS: Soft tissue coverage was effective in all cases. Two patients required re-intervention due to flap-related complications (venous congestion and partial flap necrosis). All patients fully recovered over a mean±standard deviation follow-up of 2.4±1.5 years. CONCLUSIONS: Abdominal flaps can be an effective and simple alternative technique for inguinal coverage with reproducible outcomes. In our experience, the main indications are a compromised deep femoral artery network and poor thigh tissue quality. Relative contraindications, such as previous open abdominal surgery, should be considered.

Transposition of intravascular lipid in experimentally induced fat embolism: a preliminary study

Panniculectomy & Abdominoplasty CPG

BACKGROUND: Liposuction is a procedure to reduce the volume of subcutaneous fat by physical force. Intracellular storage fat is composed of triglyceride, whereas circulating fat particles exist as cholesterol or triglycerol bound to carrier proteins. It is unavoidable that the storage form of fat particles enters the circulation system after these particles are physiologically destroyed. To date, however, no studies have clarified the fatal characteristics of fat embolism that occurs after the subclinical phase of free fat particles. METHODS: A mixture of human lipoaspirate and normal saline (1:100, 0.2 mL) was injected into the external jugular vein of rats, weighing 200 g on average. Biopsy specimens of the lung and kidney were examined at 12-hour intervals until postoperative 72 hours. The deposit location and transport of the injected free fat particles were confirmed histologically by an Oil Red O stain. RESULTS: Inconsistent with previous reports, free fat particles were transported from the intravascular space to the parenchyma. At 24 hours after infusion, free fat particles deposited in the vascular lumen were confirmed on the Oil Red O stain. At 72 hours after infusion, free fat particles were accumulated compactly within the parenchymal space near the perivascular area. CONCLUSIONS: Many surgeons are aware of the fatal results and undiscovered pathophysiologic mechanisms of free fat particles. Our results indicate that free fat particles, the storage form of fat that has been degraded through a physiological process, might be removed through a direct transport mechanism and phagocytotic uptake.

Effect of Extensor Muscle Strength on Meniscus Damage Progression in Subjects Without Radiologic Knee Osteoarthritis: Data From the Osteoarthritis Initiative

AMP (Acute Meniscal Pathology)

BACKGROUND: It has been demonstrated that high extensor strength decreases knee osteoarthritis symptomatic progression. However, few studies have detected a significant association between extensor strength and structural progression. METHODS: Participants in the Osteoarthritis Initiative with both muscle strength and meniscus assessment, Kellgren-Lawrence grade 1 or less, and body mass index less than 30 were enrolled. In a separate-sex analysis, participants were divided into the high and low strength groups, referring to the median value. Meniscus progression according to the Magnetic Resonance Imaging Osteoarthritis Knee Score was compared between the two groups at 12 mos (393 females and 229 males) and 24 mos (340 females and 208 males). RESULTS: In females, less overall medial meniscus progression (11.1% [17/153] vs. 23.2% [32/138], P = 0.04), less medial meniscal medial extrusion (5.2% [8/155] vs. 12.5% [18/144], P = 0.04), and less medial meniscal anterior extrusion progression (0% [0/108] vs. 5.3% [6/113], P = 0.03) were present in the high strength group at 24 mos. In males, no significant difference was detected between the high strength group and the low strength group. CONCLUSIONS: In females, higher extensor muscle strength was associated with a decreased risk of medial meniscus progression in medial and anterior extrusion.

Hinged elbow external fixation for severe elbow stiffness

Pediatric Supracondylar Humerus Fracture 2020 Review

PURPOSE OF THE STUDY The elbow is a highly constrained synovial hinge joint that frequently becomes stiff after injury. Grade 4 elbow stiffness (ankylosis) is a strongly limiting factor in the patient s daily activities and is difficult to treat. Hinged external fixation of the elbow provides the advantages of static fixation with the benefits of continued motion of the joint. The goal of our study was to assess the improvement in the range of motion of the elbow after surgical arthrolysis using a posterior extensile approach to the joint with or without using external fixation. MATERIAL AND METHODS Sixteen patients aged between 19 and 46 years with grade 4 elbow stiffness were operated on. The stiffness was caused by the following pathologies: 7 elbow dislocations, 3 radial head fractures, 4 distal humeral fractures, 2 fracture-dislocations. The average range of motion before surgery was 14° (range 0°-20°). The average interval between primary injury and arthrolysis was 24 months (9-60 months). The clinical assessment before and after the surgery was based on the Mayo Elbow Performance Score (MEPS). The average follow-up was 30 months (18-50 months). Arthrolysis was completed by application of an external fixator in eight patients. RESULTS A few common complications were observed, including the injury to adjacent neurovascular structures (two cases of temporary irritation of the ulnar nerve, one case of temporary irritation of the radial nerve) and three cases of pin-track infections. None of the patients showed elbow instability. In Group I, in which external fixation was used, the average MEP score increased from 51 points (range, 30 to 70) to 78 points (range, 55 to 90). The average range of motion at the final follow-up was 93° (range, 75°-135°). In Group II, in which no external fixation was used, the average MEP score increased from 53 points (range, 35 to 70) to 76 points (range, 55 to 85).The gain inflexion-extension was 88° (range, 65°-135°).The final improvement in the range of motion depended mostly on the severity of preoperative stiffness and subsequent surgery. DISCUSSION The surgical arthrolysis of the ankylosed elbow is not a procedure commonly performed by majority of hospitals. A precise surgical technique is a prerequisite for success of the procedure. The type of injury did not seem to influence the final result. Articular external fixation potentially provides stability while permitting the movement. CONCLUSIONS Open arthrolysis of a severe elbow contracture results in a substantial gain in motion (with or without using elbow external fixation) and gives reliable long-lasting results. The minimal improvement in motion provided by the hinge fixator does not justify the associated increase in the risk of complications.

Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: a Randomized Clinical Trial

DoD PRF (Psychosocial RF)

IMPORTANCE: Orphans and vulnerable children (OVC) are at high risk for experiencing trauma and related psychosocial problems. Despite this, no randomized clinical trials have studied evidence�based treatments for OVC in low�resource settings. OBJECTIVE: To evaluate the effectiveness of lay counselor�provided trauma�focused cognitive behavioral therapy (TF�CBT) to address trauma and stress�related symptoms among OVC in Lusaka, Zambia. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial compared TF�CBT and treatment as usual (TAU) (varying by site) for children recruited from August 1, 2012, through July 31, 2013, and treated until December 31, 2013, for trauma�related symptoms from 5 community sites within Lusaka, Zambia. Children were aged 5 through 18 years and had experienced at least one traumatic event and reported significant trauma�related symptoms. Analysis was with intent to treat. INTERVENTIONS: The intervention group received 10 to 16 sessions of TF�CBT (n = 131). The TAU group (n = 126) received usual community services offered to OVC. MAIN OUTCOMES AND MEASURES: The primary outcome was mean item change in trauma and stress�related symptoms using a locally validated version of the UCLA Posttraumatic Stress Disorder Reaction Index (range, 0�4) and functional impairment using a locally developed measure (range, 0�4). Outcomes were measured at baseline and within 1 month after treatment completion or after a waiting period of approximately 4.5 months after baseline for TAU. RESULTS: At follow�up, the mean item change in trauma symptom score was �1.54 (95% CI, �1.81 to �1.27), a reduction of 81.9%, for the TF�CBT group and �0.37 (95% CI, �0.57 to �0.17), a reduction of 21.1%, for the TAU group. The mean item change for functioning was �0.76 (95% CI, �0.98 to �0.54), a reduction of 89.4%, and �0.54 (95% CI, �0.80 to �0.29), a reduction of 68.3%, for the TF�CBT and TAU groups, respectively. The difference in change between groups was statistically significant for both outcomes (P < .001). The effect size (Cohen d) was 2.39 for trauma symptoms and 0.34 for functioning. Lay counselors participated in supervision and assessed whether the intervention was provided with fidelity in all 5 community settings. CONCLUSIONS AND RELEVANCE: The TF�CBT adapted for Zambia substantially decreased trauma and stress�related symptoms and produced a smaller improvement in functional impairment among OVC having experienced high levels of trauma. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01624298.

Immediate effects of self-manual therapy and supervised manual therapy in individuals with knee osteoarthritis

OAK 3 - Non-arthroplasty tx of OAK

Background and Objective: Knee osteoarthritis is the degenerative disease that leads to pain, impaired mobility, poor function and frequent absence from work. The self-manual therapy affects to decrease pain and improve knee motions. However, the evidence of the different of the self-manual therapy and supervised manual therapy is lacking. This study aimed to compare the immediate effects of self-manual therapy with and without supervised manual therapy in individuals with knee osteoarthritis. Materials and Method: Twenty four participants with knee osteoarthritis were randomly assigned into three groups; self-manual therapy group (n=8; 2 men and 6 women [age 74.00 ± 10.82 years]) PT manual therapy group (n=8; 2 men and 6 women [age72.25 ± 10.75years]) and control group (n=8; 8 women [age73.25 ± 8.84 years]). The participants were received self-manual therapy or physical therapistâ??s manual therapy. Repeated measures ANOVA were used to determine effects for pressure pain threshold, knee range of motion and time up and go within group and between groups. Results: These results showed that the self-manual therapy group significantly decreased pain after treatment. The PT manual therapy group showed significantly decrease pain and improves knee flexion and extension. No significant differences. There was no significant different in time up and go. Conclusion: The self-manual therapy is an alternative treatment for pain reduction in individuals with knee OA. However, the PT manual therapy had superior benefits in improving knee range of motions.